- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,297.43 / $9,297.43 / $9,297.43
| Professional | | $9,297.43 | $9,297.43 | $9,297.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $4,865.01
| Facility | | $4,865.01 | $4,865.01 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $4,865.01 / $5,010.96
| Professional | | $3,551.46 | $4,865.01 | $5,010.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,988.15 / $1,988.15 / $1,988.15
| Facility | | $1,988.15 | $1,988.15 | $1,988.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,819.08 / $10,086.62 / $15,926.25
| Professional | | $7,819.08 | $10,086.62 | $15,926.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,988.15 / $1,988.15 / $4,865.01
| Facility | | $1,988.15 | $1,988.15 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $5,010.96 / $7,834.03
| Professional | | $3,551.46 | $5,010.96 | $7,834.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,131.68 / $5,296.96 / $10,152.50
| Professional | | $5,131.68 | $5,296.96 | $10,152.50 |