- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,011.87 / $10,232.93
| Professional | | $3,801.89 | $5,011.87 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,754.40 / $6,606.93
| Professional | | $3,981.07 | $5,754.40 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,244.36 / $8,128.31
| Facility | | $6,309.57 | $7,244.36 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,244.36 / $8,128.31
| Professional | | $6,309.57 | $7,244.36 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $6,606.93
| Facility | | $3,801.89 | $5,128.61 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,981.07 / $8,709.64
| Professional | | $79.43 | $3,981.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,760.83 / $10,471.29
| Professional | | $5,495.41 | $6,760.83 | $10,471.29 |