- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,467.37 / $3,548.13
| Professional | | $2,818.38 | $3,467.37 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Professional | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $11,220.18
| Facility | | $3,715.35 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $11,220.18
| Professional | | $3,715.35 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,370.32 / $8,128.31
| Facility | | $3,311.31 | $5,370.32 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,311.31 / $5,370.32
| Professional | | $79.43 | $3,311.31 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,715.35
| Professional | | $1,548.82 | $1,548.82 | $3,715.35 |