- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.36 / $3,439.53 / $3,439.53
| Professional | | $2,231.36 | $3,439.53 | $3,439.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,542.10 / $5,884.73 / $10,908.42
| Facility | | $4,542.10 | $5,884.73 | $10,908.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.31 / $2,660.78 / $3,834.05
| Professional | | $2,547.31 | $2,660.78 | $3,834.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $3,753.54
| Facility | | $3,006.81 | $3,006.81 | $3,753.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $2,194.96 / $3,006.81
| Professional | | $2,194.96 | $2,194.96 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,134.85 / $4,134.85 / $4,134.85
| Professional | | $4,134.85 | $4,134.85 | $4,134.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,875.54 / $3,439.53 / $3,439.53
| Professional | | $2,875.54 | $3,439.53 | $3,439.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $3,134.16 / $5,859.13
| Professional | | $1,698.53 | $3,134.16 | $5,859.13 |