- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $2,818.38
| Professional | | $2,238.72 | $2,754.23 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $8,912.51
| Facility | | $2,884.03 | $3,801.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $8,912.51
| Professional | | $2,884.03 | $3,801.89 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,265.80 / $6,456.54
| Facility | | $2,570.40 | $4,265.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,630.27 / $4,265.80
| Professional | | $79.43 | $2,630.27 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,884.03
| Professional | | $1,230.27 | $1,230.27 | $2,884.03 |