- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.83 / $4,147.76 / $4,147.76
| Professional | | $2,958.83 | $4,147.76 | $4,147.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $1,642.21 / $8,648.44
| Professional | | $513.41 | $1,642.21 | $8,648.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,990.18 / $4,147.76 / $5,203.09
| Facility | | $1,990.18 | $4,147.76 | $5,203.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,490.00 / $3,490.00 / $3,490.00
| Professional | | $3,490.00 | $3,490.00 | $3,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.18 / $3,007.26 / $4,898.20
| Professional | | $1,990.18 | $3,007.26 | $4,898.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,465.88 / $32,557.45 / $32,557.45
| Facility | | $5,465.88 | $32,557.45 | $32,557.45 |