- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.55 / $2,278.16 / $11,877.50
| Professional | | $1,933.55 | $2,278.16 | $11,877.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,624.87 / $3,624.87 / $3,624.87
| Facility | | $3,624.87 | $3,624.87 | $3,624.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.54 / $3,610.24 / $6,538.21
| Professional | | $2,166.54 | $3,610.24 | $6,538.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,232.79 / $3,005.43 / $4,175.13
| Facility | | $2,232.79 | $3,005.43 | $4,175.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,278.53 / $3,709.70 / $6,181.68
| Professional | | $2,278.53 | $3,709.70 | $6,181.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,168.73 / $3,891.19 / $5,046.39
| Professional | | $3,168.73 | $3,891.19 | $5,046.39 |