- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $5,623.41
| Professional | | $1,905.46 | $2,344.23 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,884.03 / $6,309.57
| Professional | | $1,862.09 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $4,073.80
| Facility | | $3,548.13 | $3,715.35 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $4,073.80
| Professional | | $3,548.13 | $3,715.35 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $5,128.61
| Facility | | $1,995.26 | $2,884.03 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,388.44 / $5,623.41
| Professional | | $79.43 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,467.37 / $4,365.16
| Professional | | $2,754.23 | $3,467.37 | $4,365.16 |