- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.79 / $4,128.79 / $4,128.79
| Professional | | $4,128.79 | $4,128.79 | $4,128.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $2,728.17
| Facility | | $2,728.17 | $2,728.17 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $1,991.56
| Professional | | $1,991.56 | $1,991.56 | $1,991.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.01 / $1,277.01 / $1,277.01
| Facility | | $1,277.01 | $1,277.01 | $1,277.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,479.25 / $4,644.66 / $7,072.50
| Professional | | $4,479.25 | $4,644.66 | $7,072.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.01 / $1,277.01 / $2,728.17
| Facility | | $1,277.01 | $1,277.01 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $3,626.06 / $5,525.39
| Professional | | $1,991.56 | $3,626.06 | $5,525.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.26 / $2,352.26 / $4,508.51
| Professional | | $2,352.26 | $2,352.26 | $4,508.51 |