- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $7,413.10
| Professional | | $1,995.26 | $2,818.38 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $9,549.93 / $11,220.18
| Facility | | $6,918.31 | $9,549.93 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $5,128.61
| Professional | | $2,344.23 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,884.03
| Facility | | $2,754.23 | $2,754.23 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,884.03
| Professional | | $2,089.30 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $6,165.95
| Facility | | $3,019.95 | $3,548.13 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $3,981.07
| Professional | | $2,238.72 | $2,884.03 | $3,981.07 |