- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.35 / $2,665.79 / $13,949.40
| Professional | | $2,395.35 | $2,665.79 | $13,949.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.25 / $4,570.25 / $4,570.25
| Facility | | $4,570.25 | $4,570.25 | $4,570.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.71 / $4,380.13 / $7,575.49
| Professional | | $2,606.71 | $4,380.13 | $7,575.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.34 / $3,558.23 / $5,192.83
| Facility | | $2,671.34 | $3,558.23 | $5,192.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,849.37 / $4,656.53 / $7,705.86
| Professional | | $2,849.37 | $4,656.53 | $7,705.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,819.39 / $4,669.26 / $6,215.88
| Professional | | $3,819.39 | $4,669.26 | $6,215.88 |