- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,495.41 / $12,302.69
| Professional | | $4,073.80 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $6,456.54
| Professional | | $1,819.70 | $1,819.70 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $7,079.46 / $7,762.47
| Facility | | $6,918.31 | $7,079.46 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $7,079.46 / $7,762.47
| Professional | | $6,918.31 | $7,079.46 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,897.79 / $7,079.46
| Facility | | $2,344.23 | $4,897.79 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,819.70 / $7,943.28
| Professional | | $79.43 | $1,819.70 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,079.46 / $11,220.18
| Professional | | $2,884.03 | $7,079.46 | $11,220.18 |