- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,704.26 / $4,168.47 / $4,168.47
| Professional | | $2,704.26 | $4,168.47 | $4,168.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,504.74 / $7,131.90 / $13,220.28
| Facility | | $5,504.74 | $7,131.90 | $13,220.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,562.16 / $3,562.16 / $4,646.63
| Professional | | $3,562.16 | $3,562.16 | $4,646.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,549.05
| Facility | | $4,052.23 | $4,052.23 | $4,549.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $2,958.13 / $4,052.23
| Professional | | $2,958.13 | $2,958.13 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.18 / $5,011.18 / $5,011.18
| Professional | | $5,011.18 | $5,011.18 | $5,011.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,484.97 / $4,168.47 / $4,168.47
| Professional | | $3,484.97 | $4,168.47 | $4,168.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.51 / $4,195.91 / $7,100.90
| Professional | | $2,058.51 | $4,195.91 | $7,100.90 |