- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.21 / $3,022.70 / $11,317.10
| Professional | | $2,476.21 | $3,022.70 | $11,317.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,620.13 / $3,620.13 / $3,620.13
| Facility | | $3,620.13 | $3,620.13 | $3,620.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.05 / $3,462.32 / $3,620.13
| Professional | | $1,727.05 | $3,462.32 | $3,620.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,783.01 / $2,451.64 / $3,729.22
| Facility | | $1,783.01 | $2,451.64 | $3,729.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.14 / $3,462.32 / $4,698.39
| Professional | | $2,025.14 | $3,462.32 | $4,698.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,063.45 / $3,584.89 / $4,131.10
| Professional | | $3,063.45 | $3,584.89 | $4,131.10 |