- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,391.63 / $5,817.24 / $7,271.55
| Professional | | $3,391.63 | $5,817.24 | $7,271.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $7,201.58
| Facility | | $3,704.40 | $3,704.40 | $7,201.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $12,836.25
| Professional | | $782.55 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $613.99 / $6,108.10 / $7,635.13
| Facility | | $613.99 | $6,108.10 | $7,635.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.92 / $3,536.55 / $6,129.80
| Professional | | $2,121.92 | $3,536.55 | $6,129.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.92 / $3,518.48 / $6,129.80
| Professional | | $2,121.92 | $3,518.48 | $6,129.80 |