- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $6,456.54
| Professional | | $2,951.21 | $3,630.78 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,606.93 / $21,877.62
| Facility | | $5,623.41 | $6,606.93 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $5,623.41
| Professional | | $1,819.70 | $1,819.70 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,011.87 / $11,748.98
| Facility | | $3,890.45 | $5,011.87 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,011.87 / $11,748.98
| Professional | | $3,890.45 | $5,011.87 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,606.93 / $21,877.62
| Facility | | $3,467.37 | $6,606.93 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,165.95
| Professional | | $3,467.37 | $3,467.37 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $3,890.45
| Professional | | $1,621.81 | $1,621.81 | $3,890.45 |