- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.41 / $2,361.41 / $2,361.41
| Professional | | $2,361.41 | $2,361.41 | $2,361.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,020.64 / $1,020.64
| Facility | | $1,020.64 | $1,020.64 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $1,051.26
| Professional | | $745.07 | $1,020.64 | $1,051.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.63 / $513.63 / $513.63
| Facility | | $513.63 | $513.63 | $513.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.02 / $2,561.86 / $4,045.04
| Professional | | $2,020.02 | $2,561.86 | $4,045.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.63 / $513.63 / $1,020.64
| Facility | | $513.63 | $513.63 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $2,023.88
| Professional | | $745.07 | $1,020.64 | $2,023.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.38 / $1,345.36 / $2,578.60
| Professional | | $1,303.38 | $1,345.36 | $2,578.60 |