- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.46 / $4,013.10 / $4,013.10
| Professional | | $2,603.46 | $4,013.10 | $4,013.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,299.55 / $6,866.06 / $12,727.51
| Facility | | $5,299.55 | $6,866.06 | $12,727.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,731.85 / $2,853.54 / $4,473.43
| Professional | | $2,731.85 | $2,853.54 | $4,473.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $4,379.50
| Facility | | $3,813.78 | $3,813.78 | $4,379.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $2,784.06 / $3,813.78
| Professional | | $2,784.06 | $2,784.06 | $3,813.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,824.39 / $4,824.39 / $4,824.39
| Professional | | $4,824.39 | $4,824.39 | $4,824.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,355.07 / $4,013.10 / $4,013.10
| Professional | | $3,355.07 | $4,013.10 | $4,013.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.78 / $2,972.66 / $6,836.21
| Professional | | $1,981.78 | $2,972.66 | $6,836.21 |