- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.31 / $3,842.78 / $16,140.60
| Professional | | $2,169.31 | $3,842.78 | $16,140.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,201.47 / $4,201.47 / $4,201.47
| Facility | | $4,201.47 | $4,201.47 | $4,201.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,266.42 / $6,266.42 / $6,266.42
| Professional | | $6,266.42 | $6,266.42 | $6,266.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,201.47 / $4,201.47 / $4,201.47
| Facility | | $4,201.47 | $4,201.47 | $4,201.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.36 / $2,014.36 / $6,266.42
| Professional | | $2,014.36 | $2,014.36 | $6,266.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.46 / $3,099.02 / $5,799.59
| Professional | | $1,096.46 | $3,099.02 | $5,799.59 |