- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.96 / $3,166.30 / $3,166.30
| Professional | | $2,222.96 | $3,166.30 | $3,166.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,181.30 / $5,417.26 / $10,041.89
| Facility | | $4,181.30 | $5,417.26 | $10,041.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.13 / $3,000.07 / $3,529.49
| Professional | | $2,872.13 | $3,000.07 | $3,529.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,295.83 / $3,798.08 / $3,798.08
| Facility | | $3,295.83 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $2,772.60 / $3,798.08
| Professional | | $2,772.60 | $2,772.60 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,806.40 / $3,806.40 / $3,806.40
| Professional | | $3,806.40 | $3,806.40 | $3,806.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,647.12 / $3,166.30 / $3,166.30
| Professional | | $2,647.12 | $3,166.30 | $3,166.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $3,533.81 / $5,393.71
| Professional | | $1,563.60 | $3,533.81 | $5,393.71 |