- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.65 / $2,151.48 / $2,856.27
| Professional | | $2,096.65 | $2,151.48 | $2,856.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,683.24 / $4,683.24 / $7,473.86
| Facility | | $4,683.24 | $4,683.24 | $7,473.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.73 / $722.54 / $2,422.78
| Professional | | $614.73 | $722.54 | $2,422.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,683.24 / $4,683.24 / $7,473.86
| Facility | | $4,683.24 | $4,683.24 | $7,473.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.05 / $722.54 / $2,422.78
| Professional | | $626.05 | $722.54 | $2,422.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.79 / $2,179.38 / $13,575.69
| Professional | | $748.79 | $2,179.38 | $13,575.69 |