- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.44 / $1,881.10 / $2,957.24
| Professional | | $1,777.44 | $1,881.10 | $2,957.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.46 / $3,964.56 / $7,167.76
| Facility | | $1,097.46 | $3,964.56 | $7,167.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.64 / $3,658.19 / $4,984.29
| Professional | | $2,743.64 | $3,658.19 | $4,984.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $4,698.38
| Professional | | $2,732.53 | $2,732.53 | $4,698.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.07 / $2,793.11 / $18,916.50
| Facility | | $1,165.07 | $2,793.11 | $18,916.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.10 / $1,804.68 / $2,780.96
| Professional | | $1,631.10 | $1,804.68 | $2,780.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.10 / $1,804.68 / $2,718.50
| Professional | | $1,631.10 | $1,804.68 | $2,718.50 |