- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.80 / $2,443.31 / $2,637.20
| Professional | | $1,942.80 | $2,443.31 | $2,637.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,286.73 / $8,491.04 / $10,052.40
| Facility | | $6,286.73 | $8,491.04 | $10,052.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,986.25 / $2,336.76 / $3,908.06
| Professional | | $1,986.25 | $2,336.76 | $3,908.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.60 / $3,364.97 / $3,364.97
| Facility | | $1,577.60 | $3,364.97 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $3,364.97 / $3,364.97
| Professional | | $2,456.42 | $3,364.97 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.53 / $2,834.29 / $3,697.19
| Professional | | $2,029.53 | $2,834.29 | $3,697.19 |