- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $3,388.44
| Professional | | $2,187.76 | $2,884.03 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,365.16
| Facility | | $3,548.13 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,715.35
| Professional | | $2,630.27 | $2,630.27 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,248.07 / $6,456.54
| Professional | | $4,677.35 | $5,248.07 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,235.94 / $4,365.16
| Facility | | $3,162.28 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,466.84 / $12,302.69
| Professional | | $2,041.74 | $4,466.84 | $12,302.69 |