- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.33 / $2,561.37 / $2,561.37
| Professional | | $1,935.33 | $2,561.37 | $2,561.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,753.13 / $4,862.52 / $9,013.58
| Facility | | $3,753.13 | $4,862.52 | $9,013.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.62 / $2,254.39 / $2,254.39
| Professional | | $2,151.62 | $2,254.39 | $2,254.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,507.59 / $3,101.56
| Facility | | $2,507.59 | $2,507.59 | $3,101.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $1,830.54 / $2,507.59
| Professional | | $1,830.54 | $1,830.54 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,416.61 / $3,416.61 / $3,416.61
| Professional | | $3,416.61 | $3,416.61 | $3,416.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.06 / $2,561.37 / $2,561.37
| Professional | | $2,376.06 | $2,561.37 | $2,561.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.49 / $2,105.23 / $4,841.39
| Professional | | $1,403.49 | $2,105.23 | $4,841.39 |