- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.78 / $2,369.29 / $2,463.42
| Professional | | $1,814.78 | $2,369.29 | $2,463.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,872.47 / $7,931.50 / $9,389.95
| Facility | | $5,872.47 | $7,931.50 | $9,389.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,712.89 / $2,712.89 / $3,756.05
| Professional | | $2,712.89 | $2,712.89 | $3,756.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $2,481.10
| Facility | | $2,481.10 | $2,481.10 | $2,481.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $2,481.10 / $2,481.10
| Professional | | $1,811.20 | $2,481.10 | $2,481.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.65 / $2,600.65 / $2,600.65
| Facility | | $2,600.65 | $2,600.65 | $2,600.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.50 / $2,647.52 / $3,453.55
| Professional | | $1,950.50 | $2,647.52 | $3,453.55 |