- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.07 / $2,172.62 / $2,533.06
| Professional | | $1,866.07 | $2,172.62 | $2,533.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,038.45 / $8,155.73 / $9,655.43
| Facility | | $6,038.45 | $8,155.73 | $9,655.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.81 / $2,244.48 / $3,753.73
| Professional | | $1,907.81 | $2,244.48 | $3,753.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $3,214.74 / $3,214.74
| Professional | | $2,732.53 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.87 / $2,439.07 / $3,551.19
| Professional | | $1,840.87 | $2,439.07 | $3,551.19 |