- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.21 / $4,493.64 / $4,493.64
| Professional | | $2,915.21 | $4,493.64 | $4,493.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,934.16 / $7,688.25 / $14,251.58
| Facility | | $5,934.16 | $7,688.25 | $14,251.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,194.59 / $3,352.35 / $5,009.10
| Professional | | $3,194.59 | $3,352.35 | $5,009.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $4,903.91
| Facility | | $3,943.38 | $3,943.38 | $4,903.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $2,878.67 / $3,943.38
| Professional | | $2,878.67 | $2,878.67 | $3,943.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,402.08 / $5,402.08 / $5,402.08
| Professional | | $5,402.08 | $5,402.08 | $5,402.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,756.83 / $4,493.64 / $4,493.64
| Professional | | $3,756.83 | $4,493.64 | $4,493.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.08 / $3,328.63 / $7,654.81
| Professional | | $2,219.08 | $3,328.63 | $7,654.81 |