- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,265.80 / $9,120.11
| Professional | | $3,162.28 | $4,265.80 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,248.07 / $5,623.41
| Professional | | $3,311.31 | $5,248.07 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,754.40 / $6,309.57
| Facility | | $5,495.41 | $5,754.40 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,754.40 / $6,309.57
| Professional | | $5,495.41 | $5,754.40 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,786.30 / $5,623.41
| Facility | | $3,019.95 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,311.31 / $6,918.31
| Professional | | $79.43 | $3,311.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $8,128.31
| Professional | | $4,466.84 | $5,495.41 | $8,128.31 |