- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,630.78 / $4,365.16
| Professional | | $3,548.13 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $8,511.38 / $8,511.38
| Facility | | $2,398.83 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $1,380.38 / $6,456.54
| Facility | | $109.65 | $1,380.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $912.01 / $1,659.59
| Professional | | $741.31 | $912.01 | $1,659.59 |