- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.16 / $2,813.40 / $2,813.40
| Professional | | $1,825.16 | $2,813.40 | $2,813.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.28 / $4,813.49 / $8,922.69
| Facility | | $3,715.28 | $4,813.49 | $8,922.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.55 / $2,363.34 / $3,136.11
| Professional | | $2,262.55 | $2,363.34 | $3,136.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,928.50 / $2,970.85 / $3,070.25
| Facility | | $2,928.50 | $2,970.85 | $3,070.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,168.71 / $2,970.85
| Professional | | $2,168.71 | $2,168.71 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,382.15 / $3,382.15 / $3,382.15
| Professional | | $3,382.15 | $3,382.15 | $3,382.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.08 / $2,813.40 / $2,813.40
| Professional | | $2,352.08 | $2,813.40 | $2,813.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.57 / $2,084.00 / $5,784.12
| Professional | | $1,423.57 | $2,084.00 | $5,784.12 |