- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $6,025.60
| Professional | | $3,630.78 | $4,897.79 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Professional | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,760.83 / $15,848.93
| Facility | | $5,248.07 | $6,760.83 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,760.83 / $15,848.93
| Professional | | $5,248.07 | $6,760.83 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,585.78 / $11,481.54
| Facility | | $4,677.35 | $7,585.78 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $4,677.35 / $7,585.78
| Professional | | $79.43 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $5,248.07
| Professional | | $2,187.76 | $2,187.76 | $5,248.07 |