- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,365.16 / $5,128.61
| Professional | | $3,311.31 | $4,365.16 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $7,079.46
| Professional | | $5,754.40 | $5,754.40 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $7,413.10 / $12,022.64
| Facility | | $3,311.31 | $7,413.10 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,187.76 / $3,715.35
| Professional | | $1,258.93 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $3,715.35
| Professional | | $1,258.93 | $1,862.09 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |