- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,754.23 / $6,025.60
| Professional | | $1,995.26 | $2,754.23 | $6,025.60 |
- 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
- $2,187.76 / $3,388.44 / $3,715.35
| Professional | | $2,187.76 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $4,168.69
| Facility | | $3,630.78 | $3,715.35 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $4,168.69
| Professional | | $3,630.78 | $3,715.35 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,090.30 / $3,630.78
| Facility | | $1,949.84 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,187.76 / $4,466.84
| Professional | | $79.43 | $2,187.76 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,548.13 / $5,248.07
| Professional | | $2,884.03 | $3,548.13 | $5,248.07 |