- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $2,951.21
| Professional | | $1,862.09 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,715.35
| Facility | | $2,754.23 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,884.03
| Professional | | $1,995.26 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $5,248.07
| Professional | | $3,890.45 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $3,162.28
| Facility | | $2,187.76 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,801.89 / $10,471.29
| Professional | | $1,737.80 | $3,801.89 | $10,471.29 |