- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,136.96 / $4,835.47 / $4,835.47
| Professional | | $3,136.96 | $4,835.47 | $4,835.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,385.57 / $8,273.10 / $15,335.71
| Facility | | $6,385.57 | $8,273.10 | $15,335.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,772.23 / $3,939.22 / $5,390.12
| Professional | | $3,772.23 | $3,939.22 | $5,390.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $5,276.94
| Facility | | $4,865.01 | $4,865.01 | $5,276.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $3,551.46 / $4,865.01
| Professional | | $3,551.46 | $3,551.46 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,813.02 / $5,813.02 / $5,813.02
| Professional | | $5,813.02 | $5,813.02 | $5,813.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,042.59 / $4,835.47 / $4,835.47
| Professional | | $4,042.59 | $4,835.47 | $4,835.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,320.94 / $5,320.94 / $5,320.94
| Facility | | $5,320.94 | $5,320.94 | $5,320.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.89 / $3,581.84 / $8,237.10
| Professional | | $2,387.89 | $3,581.84 | $8,237.10 |