- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,691.53 / $3,019.95
| Professional | | $2,454.71 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $5,128.61
| Professional | | $4,073.80 | $5,011.87 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $10,715.19
| Facility | | $3,548.13 | $4,365.16 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $10,715.19
| Professional | | $3,548.13 | $4,365.16 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,162.28 / $4,365.16
| Professional | | $79.43 | $3,162.28 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $3,548.13
| Professional | | $1,479.11 | $1,479.11 | $3,548.13 |