- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.66 / $4,466.66 / $4,466.66
| Professional | | $4,466.66 | $4,466.66 | $4,466.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $3,141.52
| Facility | | $3,141.52 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,141.52 / $3,235.77
| Professional | | $2,293.31 | $3,141.52 | $3,235.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.07 / $1,173.07 / $1,173.07
| Facility | | $1,173.07 | $1,173.07 | $1,173.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,398.03 / $4,845.80 / $7,651.26
| Professional | | $4,398.03 | $4,845.80 | $7,651.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.07 / $1,173.07 / $3,141.52
| Facility | | $1,173.07 | $1,173.07 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,235.77 / $4,622.35
| Professional | | $2,293.31 | $3,235.77 | $4,622.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.35 / $2,544.76 / $4,877.45
| Professional | | $2,465.35 | $2,544.76 | $4,877.45 |