- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.67 / $10,936.50 / $10,936.50
| Professional | | $2,390.67 | $10,936.50 | $10,936.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,323.58 / $3,323.58 / $3,323.58
| Professional | | $3,323.58 | $3,323.58 | $3,323.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.58 / $3,323.58 / $3,323.58
| Facility | | $3,323.58 | $3,323.58 | $3,323.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,439.46 / $3,323.58 / $3,323.58
| Professional | | $2,439.46 | $3,323.58 | $3,323.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.58 / $4,031.30 / $4,168.18
| Facility | | $3,323.58 | $4,031.30 | $4,168.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.43 / $2,885.00 / $4,406.50
| Professional | | $2,036.43 | $2,885.00 | $4,406.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,163.02 / $3,734.41 / $5,822.87
| Professional | | $3,163.02 | $3,734.41 | $5,822.87 |