- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,907.96 / $3,124.42 / $4,838.14
| Professional | | $2,907.96 | $3,124.42 | $4,838.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.82 / $6,584.95 / $11,905.32
| Facility | | $1,822.82 | $6,584.95 | $11,905.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,557.07 / $6,076.09 / $8,278.67
| Professional | | $4,557.07 | $6,076.09 | $8,278.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,423.18 / $4,423.18 / $4,423.18
| Facility | | $4,423.18 | $4,423.18 | $4,423.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.92 / $3,228.92 / $7,926.75
| Professional | | $3,228.92 | $3,228.92 | $7,926.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,093.60 / $3,478.55 / $33,517.87
| Facility | | $2,093.60 | $3,478.55 | $33,517.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,931.04 / $3,242.96 / $4,997.30
| Professional | | $2,931.04 | $3,242.96 | $4,997.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,931.04 / $3,242.96 / $4,885.06
| Professional | | $2,931.04 | $3,242.96 | $4,885.06 |