- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.87 / $2,988.67 / $2,988.67
| Professional | | $1,938.87 | $2,988.67 | $2,988.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,946.73 / $5,113.35 / $9,478.54
| Facility | | $3,946.73 | $5,113.35 | $9,478.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.81 / $2,591.81 / $3,331.48
| Professional | | $2,591.81 | $2,591.81 | $3,331.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,941.06
| Professional | | $2,146.96 | $2,146.96 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,592.86 / $3,592.86 / $3,592.86
| Professional | | $3,592.86 | $3,592.86 | $3,592.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,498.61 / $2,988.67 / $2,988.67
| Professional | | $2,498.61 | $2,988.67 | $2,988.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.19 / $2,213.83 / $5,091.12
| Professional | | $1,561.19 | $2,213.83 | $5,091.12 |