- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $6,309.57
| Professional | | $2,187.76 | $2,951.21 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,801.89 / $4,168.69
| Professional | | $2,511.89 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,168.69 / $4,677.35
| Facility | | $3,162.28 | $4,168.69 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,168.69 / $4,677.35
| Professional | | $3,162.28 | $4,168.69 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,235.94 / $3,981.07
| Facility | | $2,187.76 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,511.89 / $5,011.87
| Professional | | $79.43 | $2,511.89 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $5,888.44
| Professional | | $3,162.28 | $3,890.45 | $5,888.44 |