- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,570.88 / $11,748.98
| Professional | | $3,467.37 | $4,570.88 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $5,370.32
| Professional | | $4,365.16 | $4,365.16 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,025.60 / $6,606.93
| Facility | | $5,754.40 | $6,025.60 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,025.60 / $6,606.93
| Professional | | $5,754.40 | $6,025.60 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,754.40 / $6,456.54
| Facility | | $4,073.80 | $5,754.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,311.31 / $6,606.93
| Professional | | $79.43 | $3,311.31 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,025.60 / $9,332.54
| Professional | | $5,011.87 | $6,025.60 | $9,332.54 |