- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,951.21 / $5,623.41
| Professional | | $2,089.30 | $2,951.21 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $3,630.78
| Professional | | $1,819.70 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $3,981.07
| Facility | | $3,630.78 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $3,981.07
| Professional | | $3,630.78 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,162.28 / $4,677.35
| Facility | | $2,137.96 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,951.21 / $4,365.16
| Professional | | $79.43 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $4,168.69
| Professional | | $2,754.23 | $3,548.13 | $4,168.69 |