- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.71 / $3,244.31 / $3,244.31
| Professional | | $2,104.71 | $3,244.31 | $3,244.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,284.32 / $5,550.73 / $10,289.29
| Facility | | $4,284.32 | $5,550.73 | $10,289.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,813.51 / $2,813.51 / $3,616.45
| Professional | | $2,813.51 | $2,813.51 | $3,616.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $3,540.51
| Facility | | $2,801.20 | $2,801.20 | $3,540.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $2,801.20
| Professional | | $2,044.88 | $2,044.88 | $2,801.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,900.18 / $3,900.18 / $3,900.18
| Professional | | $3,900.18 | $3,900.18 | $3,900.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,712.34 / $3,244.31 / $3,244.31
| Professional | | $2,712.34 | $3,244.31 | $3,244.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.13 / $2,403.19 / $5,526.59
| Professional | | $1,602.13 | $2,403.19 | $5,526.59 |