- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.08 / $2,035.43 / $2,219.51
| Professional | | $1,635.08 | $2,035.43 | $2,219.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,290.99 / $7,146.16 / $8,460.20
| Facility | | $5,290.99 | $7,146.16 | $8,460.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.65 / $1,966.65 / $3,289.07
| Professional | | $1,966.65 | $1,966.65 | $3,289.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.65 / $2,677.88 / $2,677.88
| Facility | | $2,162.65 | $2,677.88 | $2,677.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,677.88 / $2,677.88
| Professional | | $1,954.85 | $2,677.88 | $2,677.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.72 / $2,145.17 / $3,111.60
| Professional | | $1,690.72 | $2,145.17 | $3,111.60 |