- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,479.42 / $4,479.42 / $4,479.42
| Professional | | $4,479.42 | $4,479.42 | $4,479.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.04 / $2,550.04 / $2,550.04
| Facility | | $2,550.04 | $2,550.04 | $2,550.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $2,550.04 / $2,990.32
| Professional | | $1,861.53 | $2,550.04 | $2,990.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,314.38 / $1,314.38 / $1,314.38
| Facility | | $1,314.38 | $1,314.38 | $1,314.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,859.64 / $5,059.45 / $7,673.13
| Professional | | $4,859.64 | $5,059.45 | $7,673.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,314.38 / $1,314.38 / $2,550.04
| Facility | | $1,314.38 | $1,314.38 | $2,550.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $2,990.32 / $5,179.12
| Professional | | $1,861.53 | $2,990.32 | $5,179.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,552.03 / $2,552.03 / $4,891.39
| Professional | | $2,552.03 | $2,552.03 | $4,891.39 |