- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.71 / $2,648.01 / $2,857.00
| Professional | | $2,104.71 | $2,648.01 | $2,857.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,810.66 / $9,198.70 / $10,890.20
| Facility | | $6,810.66 | $9,198.70 | $10,890.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.78 / $2,531.51 / $4,233.77
| Professional | | $2,151.78 | $2,531.51 | $4,233.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $2,801.20
| Facility | | $2,801.20 | $2,801.20 | $2,801.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $2,044.88
| Professional | | $2,044.88 | $2,044.88 | $2,044.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,172.04 / $3,155.55 / $4,005.32
| Professional | | $2,172.04 | $3,155.55 | $4,005.32 |