- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.28 / $1,908.56 / $2,365.02
| Professional | | $1,742.28 | $1,908.56 | $2,365.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,637.87 / $7,614.66 / $9,014.86
| Facility | | $5,637.87 | $7,614.66 | $9,014.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.25 / $2,095.59 / $3,504.70
| Professional | | $1,781.25 | $2,095.59 | $3,504.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,306.50 / $2,476.09 / $2,476.09
| Facility | | $2,306.50 | $2,476.09 | $2,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $2,476.09 / $2,476.09
| Professional | | $1,807.55 | $2,476.09 | $2,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.02 / $2,277.26 / $3,315.60
| Professional | | $1,798.02 | $2,277.26 | $3,315.60 |