- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.38 / $3,597.71 / $3,643.25
| Professional | | $2,650.38 | $3,597.71 | $3,643.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,576.42 / $11,583.59 / $13,713.62
| Facility | | $8,576.42 | $11,583.59 | $13,713.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.66 / $3,187.84 / $5,331.43
| Professional | | $2,709.66 | $3,187.84 | $5,331.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $3,790.37
| Facility | | $3,790.37 | $3,790.37 | $3,790.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $3,790.37 / $3,790.37
| Professional | | $2,766.97 | $3,790.37 | $3,790.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,735.17 / $4,009.01 / $5,043.75
| Professional | | $2,735.17 | $4,009.01 | $5,043.75 |