- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,375.37 / $15,175.80 / $15,175.80
| Professional | | $4,375.37 | $15,175.80 | $15,175.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,852.38 / $3,852.38 / $3,852.38
| Professional | | $3,852.38 | $3,852.38 | $3,852.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $4,142.08 / $4,142.08
| Facility | | $2,481.10 | $4,142.08 | $4,142.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.10 / $3,368.38 / $4,142.08
| Professional | | $2,481.10 | $3,368.38 | $4,142.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,199.34 / $3,944.84 / $4,142.08
| Facility | | $2,199.34 | $3,944.84 | $4,142.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.10 / $3,108.82 / $4,548.58
| Professional | | $2,481.10 | $3,108.82 | $4,548.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,965.23 / $2,965.23 / $3,116.06
| Facility | | $2,965.23 | $2,965.23 | $3,116.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.74 / $1,968.04 / $3,121.29
| Professional | | $1,778.74 | $1,968.04 | $3,121.29 |