- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,606.93
| Professional | | $4,897.79 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $3,467.37 / $5,495.41
| Professional | | $501.19 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $8,912.51
| Facility | | $3,467.37 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,467.37 / $8,128.31
| Professional | | $79.43 | $3,467.37 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $2,691.53 / $4,897.79
| Facility | | $269.15 | $2,691.53 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,090.30 / $3,630.78
| Professional | | $2,818.38 | $3,090.30 | $3,630.78 |