- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.36 / $2,748.86 / $2,913.53
| Professional | | $2,146.36 | $2,748.86 | $2,913.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,945.43 / $9,380.70 / $11,105.66
| Facility | | $6,945.43 | $9,380.70 | $11,105.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,581.61 / $2,581.61 / $4,317.53
| Professional | | $2,581.61 | $2,581.61 | $4,317.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,841.43 / $3,532.34 / $3,532.34
| Facility | | $2,841.43 | $3,532.34 | $3,532.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $3,532.34 / $3,532.34
| Professional | | $2,578.61 | $3,532.34 | $3,532.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.02 / $3,044.43 / $4,084.56
| Professional | | $2,215.02 | $3,044.43 | $4,084.56 |