- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.69 / $1,988.34 / $2,015.36
| Professional | | $1,484.69 | $1,988.34 | $2,015.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,804.33 / $6,488.86 / $7,682.05
| Facility | | $4,804.33 | $6,488.86 | $7,682.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.90 / $1,785.76 / $2,986.54
| Professional | | $1,517.90 | $1,785.76 | $2,986.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,965.49 / $2,482.86 / $2,482.86
| Facility | | $1,965.49 | $2,482.86 | $2,482.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $2,482.86 / $2,482.86
| Professional | | $1,812.49 | $2,482.86 | $2,482.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.50 / $2,182.50 / $2,182.50
| Facility | | $2,182.50 | $2,182.50 | $2,182.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.73 / $2,165.96 / $2,825.40
| Professional | | $1,595.73 | $2,165.96 | $2,825.40 |