- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $2,691.53
| Professional | | $2,089.30 | $2,570.40 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $8,317.64
| Facility | | $2,754.23 | $3,548.13 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $8,317.64
| Professional | | $2,754.23 | $3,548.13 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,981.07 / $6,025.60
| Facility | | $2,454.71 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,454.71 / $3,981.07
| Professional | | $79.43 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $2,754.23
| Professional | | $1,148.15 | $1,148.15 | $2,754.23 |