- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.79 / $2,404.41 / $2,522.19
| Professional | | $1,729.79 | $2,404.41 | $2,522.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,597.45 / $7,560.08 / $8,950.25
| Facility | | $5,597.45 | $7,560.08 | $8,950.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.32 / $2,739.20 / $3,580.17
| Professional | | $2,328.32 | $2,739.20 | $3,580.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $3,001.57
| Professional | | $2,191.15 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.14 / $2,798.06 / $3,291.83
| Professional | | $1,826.14 | $2,798.06 | $3,291.83 |