- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $3,311.31
| Professional | | $2,630.27 | $3,235.94 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $6,760.83
| Facility | | $3,467.37 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $6,760.83
| Professional | | $3,467.37 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,011.87 / $7,585.78
| Facility | | $3,090.30 | $5,011.87 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $4,265.80 / $5,011.87
| Professional | | $85.11 | $4,265.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $3,467.37
| Professional | | $1,445.44 | $1,445.44 | $3,467.37 |