- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,801.89 / $9,332.54
| Professional | | $3,162.28 | $3,801.89 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $10,471.29
| Professional | | $3,235.94 | $4,677.35 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,025.60 / $6,456.54
| Facility | | $5,495.41 | $6,025.60 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,025.60 / $6,456.54
| Professional | | $5,495.41 | $6,025.60 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,677.35 / $8,317.64
| Facility | | $3,311.31 | $4,677.35 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $5,623.41 / $9,120.11
| Professional | | $79.43 | $5,623.41 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,623.41 / $7,244.36
| Professional | | $4,466.84 | $5,623.41 | $7,244.36 |