- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.84 / $3,386.32 / $3,386.32
| Professional | | $2,196.84 | $3,386.32 | $3,386.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,471.85 / $5,793.70 / $10,739.68
| Facility | | $4,471.85 | $5,793.70 | $10,739.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.26 / $2,530.21 / $3,774.76
| Professional | | $2,396.26 | $2,530.21 | $3,774.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $3,695.49
| Facility | | $2,728.17 | $2,728.17 | $3,695.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $2,728.17
| Professional | | $1,991.56 | $1,991.56 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,070.90 / $4,070.90 / $4,070.90
| Professional | | $4,070.90 | $4,070.90 | $4,070.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.07 / $3,386.32 / $3,386.32
| Professional | | $2,831.07 | $3,386.32 | $3,386.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.26 / $2,980.36 / $5,768.51
| Professional | | $1,672.26 | $2,980.36 | $5,768.51 |