- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,769.85 / $3,769.85 / $3,769.85
| Professional | | $3,769.85 | $3,769.85 | $3,769.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,050.41
| Facility | | $2,050.41 | $2,050.41 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $1,496.80
| Professional | | $1,496.80 | $1,496.80 | $1,496.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.83 / $919.83 / $919.83
| Facility | | $919.83 | $919.83 | $919.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,949.65 / $4,089.85 / $6,457.65
| Professional | | $2,949.65 | $4,089.85 | $6,457.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.83 / $919.83 / $2,050.41
| Facility | | $919.83 | $919.83 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $2,302.77 / $3,638.54
| Professional | | $1,496.80 | $2,302.77 | $3,638.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.75 / $2,147.77 / $4,116.55
| Professional | | $2,080.75 | $2,147.77 | $4,116.55 |