- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $8,128.31
| Professional | | $2,398.83 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,715.35
| Professional | | $2,951.21 | $2,951.21 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,168.69 / $4,677.35
| Facility | | $4,073.80 | $4,168.69 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,168.69 / $4,677.35
| Professional | | $4,073.80 | $4,168.69 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,981.07 / $4,786.30
| Facility | | $2,884.03 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,290.87 / $4,677.35
| Professional | | $79.43 | $2,290.87 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,265.80 / $6,606.93
| Professional | | $3,715.35 | $4,265.80 | $6,606.93 |