- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.82 / $2,353.73 / $2,539.50
| Professional | | $1,870.82 | $2,353.73 | $2,539.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,053.80 / $8,176.47 / $9,679.99
| Facility | | $6,053.80 | $8,176.47 | $9,679.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.67 / $2,796.67 / $3,872.06
| Professional | | $2,796.67 | $2,796.67 | $3,872.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $2,448.80
| Facility | | $2,448.80 | $2,448.80 | $2,448.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $2,448.80 / $2,448.80
| Professional | | $1,787.62 | $2,448.80 | $2,448.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.67 / $2,606.83 / $3,560.22
| Professional | | $1,930.67 | $2,606.83 | $3,560.22 |