- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,735.32 / $2,735.32 / $3,156.14
| Professional | | $2,735.32 | $2,735.32 | $3,156.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,866.16 / $14,866.16 / $19,039.15
| Facility | | $14,866.16 | $14,866.16 | $19,039.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $4,672.55
| Professional | | $3,855.99 | $4,536.46 | $4,672.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $4,672.55
| Professional | | $3,855.99 | $4,536.46 | $4,672.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,864.28 / $3,857.28 / $6,479.96
| Professional | | $1,864.28 | $3,857.28 | $6,479.96 |