- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $5,011.87
| Professional | | $2,630.27 | $3,630.78 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $5,248.07
| Facility | | $4,677.35 | $4,677.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,786.30
| Professional | | $3,467.37 | $3,467.37 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,025.60 / $8,128.31
| Professional | | $5,623.41 | $6,025.60 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,897.79
| Facility | | $4,073.80 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,370.32 / $15,135.61
| Professional | | $2,511.89 | $5,370.32 | $15,135.61 |