- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.07 / $2,530.96 / $2,705.45
| Professional | | $1,993.07 | $2,530.96 | $2,705.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,449.39 / $8,710.74 / $10,312.49
| Facility | | $6,449.39 | $8,710.74 | $10,312.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.46 / $2,568.46 / $4,125.06
| Professional | | $2,568.46 | $2,568.46 | $4,125.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $2,741.63
| Professional | | $2,001.39 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.83 / $2,907.62 / $3,792.84
| Professional | | $2,056.83 | $2,907.62 | $3,792.84 |