- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.45 / $2,961.45 / $2,961.45
| Professional | | $2,961.45 | $2,961.45 | $2,961.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,571.77 / $2,571.77
| Facility | | $2,571.77 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,571.77 / $2,648.92
| Professional | | $1,877.39 | $2,571.77 | $2,648.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.06 / $989.06 / $989.06
| Facility | | $989.06 | $989.06 | $989.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,212.82 / $3,291.45 / $5,072.88
| Professional | | $3,212.82 | $3,291.45 | $5,072.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.06 / $989.06 / $2,571.77
| Facility | | $989.06 | $989.06 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,571.77 / $3,784.02
| Professional | | $1,877.39 | $2,571.77 | $3,784.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.21 / $1,687.21 / $3,233.81
| Professional | | $1,687.21 | $1,687.21 | $3,233.81 |