- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.58 / $2,732.14 / $2,947.76
| Professional | | $2,171.58 | $2,732.14 | $2,947.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,027.04 / $9,490.93 / $11,236.15
| Facility | | $7,027.04 | $9,490.93 | $11,236.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.33 / $3,246.27 / $4,368.27
| Professional | | $2,759.33 | $3,246.27 | $4,368.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $3,294.10 / $3,294.10
| Professional | | $2,404.69 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.05 / $3,168.05 / $4,132.56
| Professional | | $2,241.05 | $3,168.05 | $4,132.56 |