- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,365.16 / $5,248.07
| Professional | | $4,265.80 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $6,456.54
| Facility | | $1,698.24 | $2,511.89 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,466.84 / $4,466.84
| Professional | | $1,862.09 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.74 / $1,995.26 / $2,041.74
| Facility | | $40.74 | $1,995.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $1,995.26 / $2,041.74
| Professional | | $40.74 | $1,995.26 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,019.95 / $6,456.54
| Facility | | $1,698.24 | $3,019.95 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,047.13 / $4,466.84
| Professional | | $79.43 | $1,047.13 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |