- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $8,912.51
| Professional | | $2,454.71 | $3,467.37 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,265.80 / $4,570.88
| Professional | | $2,290.87 | $4,265.80 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,677.35 / $5,248.07
| Facility | | $4,168.69 | $4,677.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,677.35 / $5,248.07
| Professional | | $4,168.69 | $4,677.35 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,818.38 / $4,365.16
| Facility | | $2,344.23 | $2,818.38 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,630.78 / $5,248.07
| Professional | | $79.43 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,365.16 / $5,011.87
| Professional | | $3,890.45 | $4,365.16 | $5,011.87 |