- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.42 / $2,222.50 / $2,874.26
| Professional | | $2,117.42 | $2,222.50 | $2,874.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,851.83 / $9,254.29 / $10,955.99
| Facility | | $6,851.83 | $9,254.29 | $10,955.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.82 / $2,546.82 / $4,259.35
| Professional | | $2,546.82 | $2,546.82 | $4,259.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $2,803.13
| Facility | | $2,717.61 | $2,717.61 | $2,803.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $2,717.61
| Professional | | $1,983.86 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.17 / $2,767.61 / $4,029.52
| Professional | | $2,185.17 | $2,767.61 | $4,029.52 |