- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.17 / $2,858.11 / $2,858.11
| Professional | | $2,116.17 | $2,858.11 | $2,858.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $2,549.46
| Facility | | $1,406.76 | $1,406.76 | $2,549.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,212.27 / $3,588.75 / $4,485.93
| Professional | | $3,212.27 | $3,588.75 | $4,485.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.57 / $5,798.31 / $13,890.95
| Facility | | $309.57 | $5,798.31 | $13,890.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.08 / $2,096.62 / $2,331.86
| Professional | | $1,065.08 | $2,096.62 | $2,331.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.14 / $340.53 / $340.53
| Facility | | $283.14 | $340.53 | $340.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.53 / $650.75 / $3,538.72
| Professional | | $339.53 | $650.75 | $3,538.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.96 / $1,520.06 / $2,538.55
| Professional | | $1,044.96 | $1,520.06 | $2,538.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,786.13 / $2,786.13 / $2,786.13
| Professional | | $2,786.13 | $2,786.13 | $2,786.13 |