- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.07 / $3,072.20 / $3,072.20
| Professional | | $1,993.07 | $3,072.20 | $3,072.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,057.04 / $5,256.27 / $9,743.46
| Facility | | $4,057.04 | $5,256.27 | $9,743.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.42 / $2,689.14 / $3,424.62
| Professional | | $2,578.42 | $2,689.14 | $3,424.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $2,741.63
| Professional | | $2,001.39 | $2,001.39 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,693.28 / $3,693.28 / $3,693.28
| Professional | | $3,693.28 | $3,693.28 | $3,693.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.46 / $3,072.20 / $3,072.20
| Professional | | $2,568.46 | $3,072.20 | $3,072.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.14 / $3,239.62 / $5,233.43
| Professional | | $1,517.14 | $3,239.62 | $5,233.43 |