- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $4,073.80
| Professional | | $1,202.26 | $1,659.59 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $9,549.93
| Facility | | $7,762.47 | $7,762.47 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,862.09 / $3,019.95
| Professional | | $977.24 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,187.76
| Professional | | $1,412.54 | $1,905.46 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $3,235.94
| Professional | | $1,584.89 | $1,905.46 | $3,235.94 |