- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,636.37 / $2,795.41 / $3,494.26
| Professional | | $2,636.37 | $2,795.41 | $3,494.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.37 / $2,138.42 / $2,925.66
| Facility | | $1,700.37 | $2,138.42 | $2,925.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,064.84 / $8,064.84 / $8,064.84
| Professional | | $8,064.84 | $8,064.84 | $8,064.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,205.00 / $2,205.00 / $2,205.00
| Facility | | $2,205.00 | $2,205.00 | $2,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.00 / $2,003.00 / $2,666.02
| Professional | | $1,788.00 | $2,003.00 | $2,666.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.89 / $1,875.87 / $1,875.87
| Professional | | $1,152.89 | $1,875.87 | $1,875.87 |