- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.58 / $2,859.85 / $3,186.69
| Professional | | $2,218.58 | $2,859.85 | $3,186.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,179.12 / $9,696.33 / $11,479.32
| Facility | | $7,179.12 | $9,696.33 | $11,479.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,108.06 / $4,316.03 / $4,462.80
| Professional | | $4,108.06 | $4,316.03 | $4,462.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $3,323.97
| Facility | | $3,323.97 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $3,323.97 / $3,323.97
| Professional | | $2,426.50 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.27 / $3,227.02 / $4,222.00
| Professional | | $2,420.27 | $3,227.02 | $4,222.00 |