- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.58 / $3,347.37 / $3,347.37
| Professional | | $2,171.58 | $3,347.37 | $3,347.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,420.42 / $5,727.07 / $10,616.18
| Facility | | $4,420.42 | $5,727.07 | $10,616.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,779.11 / $2,902.90 / $3,731.34
| Professional | | $2,779.11 | $2,902.90 | $3,731.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $2,404.69 / $3,294.10
| Professional | | $2,404.69 | $2,404.69 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,024.08 / $4,024.08 / $4,024.08
| Professional | | $4,024.08 | $4,024.08 | $4,024.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,798.51 / $3,347.37 / $3,347.37
| Professional | | $2,798.51 | $3,347.37 | $3,347.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.02 / $2,554.21 / $5,702.17
| Professional | | $1,653.02 | $2,554.21 | $5,702.17 |