- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.20 / $2,480.56 / $2,580.75
| Professional | | $1,901.20 | $2,480.56 | $2,580.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,152.12 / $8,309.25 / $9,837.18
| Facility | | $6,152.12 | $8,309.25 | $9,837.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.57 / $2,450.08 / $3,934.94
| Professional | | $2,082.57 | $2,450.08 | $3,934.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $3,148.57 / $3,148.57
| Professional | | $2,298.46 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.39 / $2,540.09 / $3,618.03
| Professional | | $2,043.39 | $2,540.09 | $3,618.03 |