- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.56 / $3,518.45 / $3,518.45
| Professional | | $2,282.56 | $3,518.45 | $3,518.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,646.32 / $6,019.74 / $11,158.70
| Facility | | $4,646.32 | $6,019.74 | $11,158.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,704.43 / $2,839.82 / $3,922.03
| Professional | | $2,704.43 | $2,839.82 | $3,922.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $3,839.67
| Facility | | $2,780.72 | $2,780.72 | $3,839.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,029.93 / $2,780.72
| Professional | | $2,029.93 | $2,029.93 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,229.72 / $4,229.72 / $4,229.72
| Professional | | $4,229.72 | $4,229.72 | $4,229.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,941.52 / $3,518.45 / $3,518.45
| Professional | | $2,941.52 | $3,518.45 | $3,518.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.50 / $3,345.05 / $5,993.58
| Professional | | $1,737.50 | $3,345.05 | $5,993.58 |