- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.14 / $3,226.46 / $3,226.46
| Professional | | $2,093.14 | $3,226.46 | $3,226.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,260.75 / $5,520.20 / $10,232.70
| Facility | | $4,260.75 | $5,520.20 | $10,232.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.59 / $2,913.71 / $3,596.56
| Professional | | $2,776.59 | $2,913.71 | $3,596.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $3,521.03
| Facility | | $2,853.06 | $2,853.06 | $3,521.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,082.73 / $2,853.06
| Professional | | $2,082.73 | $2,082.73 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,878.73 / $3,878.73 / $3,878.73
| Professional | | $3,878.73 | $3,878.73 | $3,878.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,697.42 / $3,226.46 / $3,226.46
| Professional | | $2,697.42 | $3,226.46 | $3,226.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.08 / $2,389.96 / $5,496.20
| Professional | | $1,755.08 | $2,389.96 | $5,496.20 |