- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,754.40 / $12,882.50
| Professional | | $4,265.80 | $5,754.40 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,079.46 / $7,762.47
| Professional | | $4,786.30 | $7,079.46 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,762.47 / $8,709.64
| Facility | | $7,585.78 | $7,762.47 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,762.47 / $8,709.64
| Professional | | $7,585.78 | $7,762.47 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,606.93 / $7,762.47
| Facility | | $4,073.80 | $6,606.93 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $4,677.35 / $9,332.54
| Professional | | $79.43 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,762.47 / $11,481.54
| Professional | | $6,309.57 | $7,762.47 | $11,481.54 |