- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,818.38 / $3,467.37
| Professional | | $2,754.23 | $2,818.38 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,943.28 / $20,417.38
| Facility | | $5,128.61 | $7,943.28 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $5,248.07
| Professional | | $2,884.03 | $2,884.03 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $5,623.41 / $5,754.40
| Facility | | $93.33 | $5,623.41 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $5,623.41 / $5,754.40
| Professional | | $93.33 | $5,623.41 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,370.32 / $20,417.38
| Facility | | $2,884.03 | $5,370.32 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,884.03 / $6,456.54
| Professional | | $79.43 | $2,884.03 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |