- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,011.87 / $7,585.78
| Professional | | $3,548.13 | $5,011.87 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,918.31 / $14,125.38
| Facility | | $2,570.40 | $6,918.31 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,918.31 / $14,125.38
| Professional | | $2,570.40 | $6,918.31 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,754.40 / $6,309.57
| Facility | | $3,548.13 | $5,754.40 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $85.11 / $7,943.28
| Professional | | $79.43 | $85.11 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,309.57 / $9,332.54
| Professional | | $5,495.41 | $6,309.57 | $9,332.54 |