- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.58 / $3,419.82 / $3,419.82
| Professional | | $2,218.58 | $3,419.82 | $3,419.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,516.09 / $5,851.01 / $10,845.92
| Facility | | $4,516.09 | $5,851.01 | $10,845.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,246.42 / $3,246.42 / $3,443.26
| Professional | | $3,246.42 | $3,246.42 | $3,443.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $3,323.97
| Facility | | $3,323.97 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $2,426.50 / $3,323.97
| Professional | | $2,426.50 | $2,426.50 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,111.17 / $4,111.17 / $4,111.17
| Professional | | $4,111.17 | $4,111.17 | $4,111.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,025.34 / $3,419.82 / $3,419.82
| Professional | | $3,025.34 | $3,419.82 | $3,419.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.79 / $3,382.48 / $5,825.58
| Professional | | $1,757.79 | $3,382.48 | $5,825.58 |