- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,704.26 / $3,352.62 / $3,670.84
| Professional | | $2,704.26 | $3,352.62 | $3,670.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,750.75 / $11,819.03 / $13,992.35
| Facility | | $8,750.75 | $11,819.03 | $13,992.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,764.74 / $3,252.64 / $5,439.79
| Professional | | $2,764.74 | $3,252.64 | $5,439.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,052.23
| Facility | | $4,052.23 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $4,052.23 / $4,052.23
| Professional | | $2,958.13 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.77 / $3,945.16 / $5,146.27
| Professional | | $2,790.77 | $3,945.16 | $5,146.27 |