- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $7,585.78
| Professional | | $1,659.59 | $2,238.72 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Professional | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $32,359.37
| Facility | | $3,981.07 | $3,981.07 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $32,359.37
| Professional | | $3,981.07 | $3,981.07 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,949.84 / $6,456.54
| Facility | | $1,819.70 | $1,949.84 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $4,897.79 / $5,495.41
| Professional | | $79.43 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $4,897.79
| Professional | | $1,513.56 | $2,238.72 | $4,897.79 |