- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.58 / $3,438.30 / $3,667.20
| Professional | | $2,701.58 | $3,438.30 | $3,667.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,742.09 / $11,807.33 / $13,978.50
| Facility | | $8,742.09 | $11,807.33 | $13,978.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.01 / $3,249.42 / $5,434.41
| Professional | | $2,762.01 | $3,249.42 | $5,434.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,799.01 / $3,799.01 / $3,799.01
| Facility | | $3,799.01 | $3,799.01 | $3,799.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,229.16 / $3,799.01 / $3,799.01
| Professional | | $3,229.16 | $3,799.01 | $3,799.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,856.01 / $3,531.13 / $5,141.18
| Professional | | $2,856.01 | $3,531.13 | $5,141.18 |