- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.41 / $2,907.35 / $2,907.35
| Professional | | $2,102.41 | $2,907.35 | $2,907.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,839.34 / $4,974.21 / $9,220.62
| Facility | | $3,839.34 | $4,974.21 | $9,220.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.27 / $2,610.27 / $3,240.84
| Professional | | $2,610.27 | $2,610.27 | $3,240.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,026.28 / $3,060.59 / $3,172.77
| Facility | | $3,026.28 | $3,060.59 | $3,172.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $3,060.59
| Professional | | $2,234.23 | $2,234.23 | $3,060.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,495.10 / $3,495.10 / $3,495.10
| Professional | | $3,495.10 | $3,495.10 | $3,495.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.63 / $2,907.35 / $2,907.35
| Professional | | $2,430.63 | $2,907.35 | $2,907.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.71 / $3,016.32 / $4,952.59
| Professional | | $1,518.71 | $3,016.32 | $4,952.59 |