- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $6,760.83
| Professional | | $2,630.27 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,466.84 / $4,677.35
| Professional | | $2,630.27 | $4,466.84 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,897.79 / $5,495.41
| Facility | | $3,890.45 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,897.79 / $5,495.41
| Professional | | $3,890.45 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $4,466.84
| Facility | | $2,570.40 | $3,467.37 | $4,466.84 |
- 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
- $3,630.78 / $4,570.88 / $6,918.31
| Professional | | $3,630.78 | $4,570.88 | $6,918.31 |