- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.37 / $2,011.37 / $2,011.37
| Professional | | $2,011.37 | $2,011.37 | $2,011.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,747.16
| Facility | | $1,747.16 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $1,799.57
| Professional | | $1,275.43 | $1,747.16 | $1,799.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.07 / $728.07 / $728.07
| Facility | | $728.07 | $728.07 | $728.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,182.09 / $2,370.13 / $3,445.41
| Professional | | $2,182.09 | $2,370.13 | $3,445.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.07 / $728.07 / $1,747.16
| Facility | | $728.07 | $728.07 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,799.57 / $2,570.71
| Professional | | $1,275.43 | $1,799.57 | $2,570.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.16 / $1,145.92 / $2,196.35
| Professional | | $1,110.16 | $1,145.92 | $2,196.35 |