- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.77 / $2,121.78 / $2,502.78
| Professional | | $1,843.77 | $2,121.78 | $2,502.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,966.26 / $8,058.21 / $9,539.98
| Facility | | $5,966.26 | $8,058.21 | $9,539.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,019.65 / $2,376.06 / $3,816.05
| Professional | | $2,019.65 | $2,376.06 | $3,816.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,440.87 / $2,507.59 / $2,507.59
| Facility | | $2,440.87 | $2,507.59 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,507.59 / $2,507.59
| Professional | | $1,830.54 | $2,507.59 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.73 / $2,105.23 / $3,508.72
| Professional | | $1,493.73 | $2,105.23 | $3,508.72 |