- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $5,495.41
| Professional | | $2,089.30 | $2,818.38 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,691.53 / $3,311.31
| Professional | | $1,621.81 | $2,691.53 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,630.78 / $3,890.45
| Facility | | $3,311.31 | $3,630.78 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,630.78 / $3,890.45
| Professional | | $3,311.31 | $3,630.78 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,951.21 / $4,365.16
| Facility | | $2,089.30 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,884.03 / $4,365.16
| Professional | | $79.43 | $2,884.03 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $4,073.80
| Professional | | $2,691.53 | $3,388.44 | $4,073.80 |