- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $5,370.32
| Professional | | $3,801.89 | $5,128.61 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Professional | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,079.46 / $16,595.87
| Facility | | $5,495.41 | $7,079.46 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,079.46 / $16,595.87
| Professional | | $5,495.41 | $7,079.46 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,943.28 / $12,022.64
| Facility | | $4,897.79 | $7,943.28 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $6,918.31
| Professional | | $79.43 | $79.43 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $5,495.41
| Professional | | $2,290.87 | $2,290.87 | $5,495.41 |