- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,715.35 / $7,079.46
| Professional | | $2,691.53 | $3,715.35 | $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
- $2,238.72 / $3,548.13 / $4,365.16
| Professional | | $2,238.72 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $5,128.61
| Facility | | $3,890.45 | $4,677.35 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $5,128.61
| Professional | | $3,890.45 | $4,677.35 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,715.35 / $4,786.30
| Facility | | $2,398.83 | $3,715.35 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,548.13 / $5,623.41
| Professional | | $79.43 | $3,548.13 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,365.16 / $5,128.61
| Professional | | $3,467.37 | $4,365.16 | $5,128.61 |