- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,685.05 / $5,685.05 / $5,685.05
| Professional | | $5,685.05 | $5,685.05 | $5,685.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $2,853.06
| Facility | | $2,853.06 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $2,938.65
| Professional | | $2,082.73 | $2,853.06 | $2,938.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.57 / $1,470.57 / $1,470.57
| Facility | | $1,470.57 | $1,470.57 | $1,470.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,608.41 / $6,167.61 / $9,738.33
| Professional | | $5,608.41 | $6,167.61 | $9,738.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.57 / $1,470.57 / $2,853.06
| Facility | | $1,470.57 | $1,470.57 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,938.65 / $5,794.56
| Professional | | $2,082.73 | $2,938.65 | $5,794.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,238.90 / $3,238.90 / $6,207.88
| Professional | | $3,238.90 | $3,238.90 | $6,207.88 |