- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.79 / $3,803.02 / $20,053.30
| Professional | | $2,920.79 | $3,803.02 | $20,053.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,128.72 / $6,128.72 / $6,128.72
| Facility | | $6,128.72 | $6,128.72 | $6,128.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,453.86 / $5,846.77 / $10,186.52
| Professional | | $3,453.86 | $5,846.77 | $10,186.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,265.02 / $4,842.66 / $6,521.08
| Facility | | $3,265.02 | $4,842.66 | $6,521.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,821.91 / $6,264.43 / $10,438.77
| Professional | | $3,821.91 | $6,264.43 | $10,438.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,344.35 / $6,367.75 / $9,779.07
| Professional | | $5,344.35 | $6,367.75 | $9,779.07 |