- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $5,888.44
| Professional | | $1,995.26 | $2,454.71 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $6,760.83
| Professional | | $1,949.84 | $2,951.21 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $4,265.80
| Facility | | $3,388.44 | $3,890.45 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $4,265.80
| Professional | | $3,388.44 | $3,890.45 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $5,248.07
| Facility | | $2,187.76 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,630.78 / $5,888.44
| Professional | | $79.43 | $3,630.78 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $4,677.35
| Professional | | $2,818.38 | $3,548.13 | $4,677.35 |