- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.86 / $3,502.63 / $10,287.70
| Professional | | $2,039.86 | $3,502.63 | $10,287.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,105.37 / $3,105.37 / $3,105.37
| Facility | | $3,105.37 | $3,105.37 | $3,105.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.56 / $3,105.37 / $3,321.47
| Professional | | $2,211.56 | $3,105.37 | $3,321.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,521.23 / $3,452.15 / $3,719.73
| Facility | | $1,521.23 | $3,452.15 | $3,719.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.45 / $2,840.46 / $4,097.10
| Professional | | $1,893.45 | $2,840.46 | $4,097.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,708.61 / $3,370.80 / $5,465.80
| Professional | | $2,708.61 | $3,370.80 | $5,465.80 |