- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.06 / $2,256.10 / $11,888.10
| Professional | | $1,929.06 | $2,256.10 | $11,888.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,632.23 / $3,632.23 / $3,632.23
| Facility | | $3,632.23 | $3,632.23 | $3,632.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.32 / $3,614.83 / $6,641.66
| Professional | | $2,134.32 | $3,614.83 | $6,641.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,211.31 / $3,008.48 / $4,157.42
| Facility | | $2,211.31 | $3,008.48 | $4,157.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.11 / $3,714.01 / $6,188.87
| Professional | | $2,281.11 | $3,714.01 | $6,188.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,173.90 / $3,877.76 / $4,874.26
| Professional | | $3,173.90 | $3,877.76 | $4,874.26 |