- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.32 / $5,754.32 / $5,754.32
| Professional | | $5,754.32 | $5,754.32 | $5,754.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,685.49 / $3,685.49 / $3,685.49
| Facility | | $3,685.49 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.67 / $3,685.49 / $3,796.05
| Professional | | $3,132.67 | $3,685.49 | $3,796.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,350.35 / $2,350.35 / $3,428.27
| Facility | | $2,350.35 | $2,350.35 | $3,428.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.29 / $523.29 / $523.29
| Professional | | $523.29 | $523.29 | $523.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.10 / $2,054.10 / $5,135.25
| Professional | | $2,054.10 | $2,054.10 | $5,135.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,350.35 / $2,350.35 / $3,685.49
| Facility | | $2,350.35 | $2,350.35 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.67 / $3,685.49 / $3,796.05
| Professional | | $3,132.67 | $3,685.49 | $3,796.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.52 / $524.26 / $913.14
| Professional | | $273.52 | $524.26 | $913.14 |