- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,630.78 / $5,128.61
| Professional | | $389.05 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $6,309.57
| Facility | | $2,691.53 | $3,388.44 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $3,630.78
| Professional | | $79.43 | $79.43 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $371.54 / $3,311.31
| Facility | | $245.47 | $371.54 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,187.76
| Professional | | $1,862.09 | $1,862.09 | $2,187.76 |