- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,660.83 / $4,660.83 / $4,660.83
| Professional | | $4,660.83 | $4,660.83 | $4,660.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $2,780.72
| Facility | | $2,780.72 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $2,964.38
| Professional | | $2,029.93 | $2,780.72 | $2,964.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.28 / $1,433.28 / $1,433.28
| Facility | | $1,433.28 | $1,433.28 | $1,433.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,622.50 / $5,056.46 / $7,983.89
| Professional | | $4,622.50 | $5,056.46 | $7,983.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.28 / $1,433.28 / $2,780.72
| Facility | | $1,433.28 | $1,433.28 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,964.38 / $5,647.62
| Professional | | $2,029.93 | $2,964.38 | $5,647.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.38 / $2,655.38 / $5,089.47
| Professional | | $2,655.38 | $2,655.38 | $5,089.47 |