- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.01 / $2,433.34 / $2,837.03
| Professional | | $2,090.01 | $2,433.34 | $2,837.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,763.09 / $9,134.42 / $10,814.08
| Facility | | $6,763.09 | $9,134.42 | $10,814.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.76 / $2,513.83 / $4,204.18
| Professional | | $2,136.76 | $2,513.83 | $4,204.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $3,600.52
| Facility | | $3,600.52 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,600.52 / $3,600.52
| Professional | | $3,060.44 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,061.76 / $2,731.76 / $3,977.33
| Professional | | $2,061.76 | $2,731.76 | $3,977.33 |