- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $5,754.40
| Professional | | $3,630.78 | $3,630.78 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $3,467.37 / $5,128.61
| Professional | | $501.19 | $3,467.37 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,760.83 / $8,709.64
| Professional | | $6,456.54 | $6,760.83 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $2,754.23 / $4,897.79
| Facility | | $363.08 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,365.16 / $7,079.46
| Professional | | $2,951.21 | $4,365.16 | $7,079.46 |