- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,812.22 / $3,812.22 / $3,812.22
| Professional | | $3,812.22 | $3,812.22 | $3,812.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $2,637.76
| Facility | | $2,637.76 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $2,716.89
| Professional | | $1,925.56 | $2,637.76 | $2,716.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.70 / $1,067.70 / $1,067.70
| Facility | | $1,067.70 | $1,067.70 | $1,067.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,078.61 / $4,135.83 / $6,530.25
| Professional | | $4,078.61 | $4,135.83 | $6,530.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.70 / $1,067.70 / $2,637.76
| Facility | | $1,067.70 | $1,067.70 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,716.89 / $4,207.12
| Professional | | $1,925.56 | $2,716.89 | $4,207.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.14 / $2,171.91 / $4,162.83
| Professional | | $2,104.14 | $2,171.91 | $4,162.83 |