- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.67 / $4,067.02 / $4,067.02
| Professional | | $3,321.67 | $4,067.02 | $4,067.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Facility | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $5,106.14
| Professional | | $560.27 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.34 / $981.27 / $6,083.28
| Professional | | $523.34 | $981.27 | $6,083.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,251.00 / $3,509.69 / $5,515.22
| Facility | | $2,251.00 | $3,509.69 | $5,515.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $5,106.14
| Professional | | $560.27 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.96 / $2,164.71 / $5,248.20
| Professional | | $2,091.96 | $2,164.71 | $5,248.20 |