- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,016.72 / $3,016.72 / $3,016.72
| Professional | | $3,016.72 | $3,016.72 | $3,016.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,425.11
| Facility | | $2,425.11 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,425.11 / $2,497.86
| Professional | | $1,770.33 | $2,425.11 | $2,497.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.02 / $1,017.02 / $1,017.02
| Facility | | $1,017.02 | $1,017.02 | $1,017.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,272.79 / $3,697.77 / $5,167.56
| Professional | | $3,272.79 | $3,697.77 | $5,167.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.02 / $1,017.02 / $2,425.11
| Facility | | $1,017.02 | $1,017.02 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,497.86 / $3,704.83
| Professional | | $1,770.33 | $2,497.86 | $3,704.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.07 / $1,718.69 / $3,294.16
| Professional | | $1,665.07 | $1,718.69 | $3,294.16 |