- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,641.83 / $3,692.80 / $4,674.72
| Professional | | $3,641.83 | $3,692.80 | $4,674.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,165.54 / $4,303.28 / $4,303.28
| Facility | | $3,165.54 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.91 / $4,303.28 / $4,303.28
| Professional | | $512.91 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,535.76 / $3,692.80 / $4,674.72
| Facility | | $3,535.76 | $3,692.80 | $4,674.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,459.60 / $5,459.60 / $5,459.60
| Professional | | $5,459.60 | $5,459.60 | $5,459.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.89 / $1,818.98 / $3,031.66
| Professional | | $181.89 | $1,818.98 | $3,031.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.23 / $2,374.16 / $3,529.20
| Professional | | $1,513.23 | $2,374.16 | $3,529.20 |