- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,286.03 / $2,286.03 / $2,286.03
| Professional | | $2,286.03 | $2,286.03 | $2,286.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $1,482.94
| Facility | | $1,482.94 | $1,482.94 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,482.94 / $1,527.43
| Professional | | $1,260.50 | $1,482.94 | $1,527.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $764.36 / $764.36 / $764.36
| Facility | | $764.36 | $764.36 | $764.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.02 / $2,430.02 / $2,430.02
| Professional | | $2,430.02 | $2,430.02 | $2,430.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $764.36 / $764.36 / $1,482.94
| Facility | | $764.36 | $764.36 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,527.43 / $2,556.46
| Professional | | $1,260.50 | $1,527.43 | $2,556.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.39 / $1,578.64 / $3,025.73
| Professional | | $1,529.39 | $1,578.64 | $3,025.73 |