- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.54 / $2,069.06 / $2,232.34
| Professional | | $1,644.54 | $2,069.06 | $2,232.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,321.60 / $7,187.57 / $8,509.25
| Facility | | $5,321.60 | $7,187.57 | $8,509.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,458.40 / $2,458.40 / $3,403.75
| Professional | | $2,458.40 | $2,458.40 | $3,403.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,326.75
| Facility | | $2,326.75 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $2,326.75
| Professional | | $1,698.53 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.28 / $1,877.77 / $3,129.62
| Professional | | $1,470.28 | $1,877.77 | $3,129.62 |