- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.13 / $2,753.43 / $2,998.73
| Professional | | $2,209.13 | $2,753.43 | $2,998.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,148.55 / $9,655.03 / $11,430.43
| Facility | | $7,148.55 | $9,655.03 | $11,430.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,258.54 / $2,657.10 / $4,443.80
| Professional | | $2,258.54 | $2,657.10 | $4,443.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,924.50 / $3,670.30 / $3,670.30
| Facility | | $2,924.50 | $3,670.30 | $3,670.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $3,670.30 / $3,670.30
| Professional | | $2,679.32 | $3,670.30 | $3,670.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.80 / $2,887.46 / $4,204.02
| Professional | | $2,279.80 | $2,887.46 | $4,204.02 |