- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $7,943.28
| Professional | | $2,187.76 | $2,570.40 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $10,471.29 / $12,022.64
| Facility | | $7,585.78 | $10,471.29 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $5,495.41
| Professional | | $2,570.40 | $3,388.44 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $3,019.95
| Facility | | $2,754.23 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,754.23
| Professional | | $2,041.74 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $6,025.60
| Facility | | $2,951.21 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $4,365.16
| Professional | | $2,344.23 | $2,951.21 | $4,365.16 |