- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.67 / $4,128.02 / $4,991.92
| Professional | | $121.67 | $4,128.02 | $4,991.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,673.22 / $4,673.22 / $4,673.22
| Facility | | $4,673.22 | $4,673.22 | $4,673.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,894.36 / $4,515.09 / $7,525.16
| Facility | | $3,894.36 | $4,515.09 | $7,525.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.02 / $4,128.02 / $7,525.16
| Professional | | $4,128.02 | $4,128.02 | $7,525.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,894.36 / $4,515.09 / $7,525.16
| Facility | | $3,894.36 | $4,515.09 | $7,525.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.02 / $4,128.02 / $7,525.16
| Professional | | $4,128.02 | $4,128.02 | $7,525.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.67 / $4,293.14 / $9,537.37
| Professional | | $72.67 | $4,293.14 | $9,537.37 |