- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.07 / $2,876.46 / $2,876.46
| Professional | | $1,866.07 | $2,876.46 | $2,876.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.55 / $4,921.37 / $9,122.66
| Facility | | $3,798.55 | $4,921.37 | $9,122.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.78 / $2,308.42 / $3,206.40
| Professional | | $2,199.78 | $2,308.42 | $3,206.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,024.96 / $3,214.74 / $3,214.74
| Facility | | $2,024.96 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,214.74
| Professional | | $2,732.53 | $2,732.53 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,457.97 / $3,457.97 / $3,457.97
| Professional | | $3,457.97 | $3,457.97 | $3,457.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.80 / $2,876.46 / $2,876.46
| Professional | | $2,404.80 | $2,876.46 | $2,876.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.48 / $2,719.10 / $4,899.97
| Professional | | $1,420.48 | $2,719.10 | $4,899.97 |