- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $5,011.87
| Professional | | $2,041.74 | $2,630.27 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,090.30 / $6,456.54
| Facility | | $1,348.96 | $3,090.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,128.61 / $9,772.37
| Professional | | $3,890.45 | $5,128.61 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,311.31
| Professional | | $2,398.83 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $10,964.78
| Facility | | $2,754.23 | $3,388.44 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,238.72 / $4,466.84
| Professional | | $2,137.96 | $2,238.72 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $4,466.84
| Facility | | $1,778.28 | $3,548.13 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,238.72 / $3,548.13
| Professional | | $2,137.96 | $2,238.72 | $3,548.13 |