- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.66 / $2,581.40 / $2,581.40
| Professional | | $1,674.66 | $2,581.40 | $2,581.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,408.89 / $4,416.54 / $8,186.86
| Facility | | $3,408.89 | $4,416.54 | $8,186.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.16 / $2,238.63 / $2,877.50
| Professional | | $2,143.16 | $2,238.63 | $2,877.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $2,817.08
| Facility | | $2,540.30 | $2,540.30 | $2,817.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $1,854.42 / $2,540.30
| Professional | | $1,854.42 | $1,854.42 | $2,540.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,103.25 / $3,103.25 / $3,103.25
| Professional | | $3,103.25 | $3,103.25 | $3,103.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.13 / $2,581.40 / $2,581.40
| Professional | | $2,158.13 | $2,581.40 | $2,581.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.44 / $1,912.15 / $4,397.34
| Professional | | $1,348.44 | $1,912.15 | $4,397.34 |