- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.42 / $3,263.91 / $3,263.91
| Professional | | $2,117.42 | $3,263.91 | $3,263.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,310.20 / $5,584.26 / $10,351.45
| Facility | | $4,310.20 | $5,584.26 | $10,351.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.71 / $2,361.41 / $3,638.31
| Professional | | $2,260.71 | $2,361.41 | $3,638.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $3,561.90
| Facility | | $2,717.61 | $2,717.61 | $3,561.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $1,983.86 / $2,717.61
| Professional | | $1,983.86 | $1,983.86 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,923.74 / $3,923.74 / $3,923.74
| Professional | | $3,923.74 | $3,923.74 | $3,923.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,728.73 / $3,263.91 / $3,263.91
| Professional | | $2,728.73 | $3,263.91 | $3,263.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.81 / $2,434.61 / $5,560.00
| Professional | | $1,611.81 | $2,434.61 | $5,560.00 |