- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.69 / $3,385.67 / $17,823.09
| Professional | | $2,371.69 | $3,385.67 | $17,823.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,371.57 / $5,371.57 / $5,371.57
| Facility | | $5,371.57 | $5,371.57 | $5,371.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.04 / $4,646.89 / $8,333.17
| Professional | | $2,666.04 | $4,646.89 | $8,333.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.76 / $3,751.36 / $5,044.16
| Facility | | $3,044.76 | $3,751.36 | $5,044.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,302.61 / $5,504.69 / $9,172.79
| Professional | | $3,302.61 | $5,504.69 | $9,172.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,314.63 / $5,367.31 / $7,309.58
| Professional | | $4,314.63 | $5,367.31 | $7,309.58 |