- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.59 / $1,766.63 / $2,326.07
| Professional | | $1,713.59 | $1,766.63 | $2,326.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,545.00 / $7,489.28 / $8,866.43
| Facility | | $5,545.00 | $7,489.28 | $8,866.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.62 / $2,561.62 / $3,546.63
| Professional | | $2,561.62 | $2,561.62 | $3,546.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $2,268.50
| Facility | | $1,902.78 | $1,902.78 | $2,268.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,902.78 / $1,902.78
| Professional | | $1,389.03 | $1,902.78 | $1,902.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.40 / $2,205.23 / $3,260.99
| Professional | | $1,768.40 | $2,205.23 | $3,260.99 |