- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,754.23 / $5,248.07
| Professional | | $2,137.96 | $2,754.23 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,311.31 / $3,548.13
| Professional | | $2,398.83 | $3,311.31 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,630.78 / $3,981.07
| Facility | | $3,548.13 | $3,630.78 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,630.78 / $3,981.07
| Professional | | $3,548.13 | $3,630.78 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $3,981.07
| Facility | | $1,862.09 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,137.96 / $4,265.80
| Professional | | $79.43 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $5,248.07
| Professional | | $3,090.30 | $3,630.78 | $5,248.07 |