- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,127.97 / $4,127.97 / $4,127.97
| Professional | | $4,127.97 | $4,127.97 | $4,127.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $2,012.35
| Professional | | $2,012.35 | $2,012.35 | $2,012.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,420.87 / $1,420.87 / $1,420.87
| Facility | | $1,420.87 | $1,420.87 | $1,420.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,577.89 / $4,577.89 / $7,228.25
| Professional | | $4,577.89 | $4,577.89 | $7,228.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,420.87 / $1,420.87 / $2,756.64
| Facility | | $1,420.87 | $1,420.87 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $3,573.94 / $5,647.07
| Professional | | $2,012.35 | $3,573.94 | $5,647.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,329.06 / $4,607.80 / $6,010.17
| Professional | | $2,329.06 | $4,607.80 | $6,010.17 |