- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,073.80 / $7,413.10
| Professional | | $2,630.27 | $4,073.80 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,570.88 / $4,897.79
| Professional | | $2,951.21 | $4,570.88 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,248.07 / $5,623.41
| Facility | | $4,677.35 | $5,248.07 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,248.07 / $5,623.41
| Professional | | $4,677.35 | $5,248.07 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,073.80 / $4,897.79
| Facility | | $2,454.71 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,754.23 / $5,888.44
| Professional | | $79.43 | $2,754.23 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,570.88 / $6,606.93
| Professional | | $3,890.45 | $4,570.88 | $6,606.93 |