- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $3,235.94
| Professional | | $1,862.09 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,073.80
| Facility | | $3,548.13 | $3,548.13 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,548.13
| Professional | | $2,570.40 | $2,570.40 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,786.30 / $5,888.44
| Professional | | $4,365.16 | $4,786.30 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,691.53 / $3,467.37
| Facility | | $2,344.23 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,168.69 / $11,481.54
| Professional | | $1,905.46 | $4,168.69 | $11,481.54 |