- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $7,079.46
| Professional | | $2,691.53 | $3,467.37 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,801.89 / $4,677.35
| Professional | | $2,089.30 | $3,801.89 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,677.35 / $5,011.87
| Facility | | $3,801.89 | $4,677.35 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,677.35 / $5,011.87
| Professional | | $3,801.89 | $4,677.35 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,630.78 / $5,495.41
| Facility | | $2,454.71 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,801.89 / $5,623.41
| Professional | | $79.43 | $3,801.89 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $5,128.61
| Professional | | $3,235.94 | $4,365.16 | $5,128.61 |