- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.80 / $2,531.46 / $2,557.67
| Professional | | $1,883.80 | $2,531.46 | $2,557.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,095.81 / $8,233.21 / $9,747.17
| Facility | | $6,095.81 | $8,233.21 | $9,747.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.93 / $2,265.80 / $3,789.40
| Professional | | $1,925.93 | $2,265.80 | $3,789.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,493.84 / $3,249.00 / $3,249.00
| Facility | | $2,493.84 | $3,249.00 | $3,249.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.77 / $3,249.00 / $3,249.00
| Professional | | $2,371.77 | $3,249.00 | $3,249.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,024.68 / $2,592.21 / $3,584.92
| Professional | | $2,024.68 | $2,592.21 | $3,584.92 |