- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $2,818.38
| Professional | | $1,819.70 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,754.23
| Professional | | $1,995.26 | $1,995.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $5,623.41
| Professional | | $3,548.13 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,311.31
| Facility | | $2,754.23 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $9,549.93
| Professional | | $1,584.89 | $3,467.37 | $9,549.93 |