- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,243.12 / $4,243.12 / $4,243.12
| Professional | | $4,243.12 | $4,243.12 | $4,243.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,561.34 / $2,561.34
| Facility | | $2,561.34 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,561.34 / $2,730.51
| Professional | | $1,869.78 | $2,561.34 | $2,730.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.06 / $1,038.06 / $1,038.06
| Facility | | $1,038.06 | $1,038.06 | $1,038.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,766.67 / $4,603.29 / $7,268.36
| Professional | | $3,766.67 | $4,603.29 | $7,268.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.06 / $1,038.06 / $2,561.34
| Facility | | $1,038.06 | $1,038.06 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,730.51 / $4,090.35
| Professional | | $1,869.78 | $2,730.51 | $4,090.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,341.96 / $2,417.40 / $4,633.35
| Professional | | $2,341.96 | $2,417.40 | $4,633.35 |