- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.14 / $2,742.31 / $2,849.21
| Professional | | $2,093.14 | $2,742.31 | $2,849.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,773.21 / $9,148.10 / $10,830.29
| Facility | | $6,773.21 | $9,148.10 | $10,830.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.66 / $3,129.01 / $4,332.18
| Professional | | $2,659.66 | $3,129.01 | $4,332.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,770.97 / $2,853.06 / $2,853.06
| Facility | | $2,770.97 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $2,853.06
| Professional | | $2,082.73 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.67 / $3,037.18 / $3,983.29
| Professional | | $2,249.67 | $3,037.18 | $3,983.29 |