- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.63 / $1,866.13 / $2,066.86
| Professional | | $1,522.63 | $1,866.13 | $2,066.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,927.10 / $6,654.72 / $7,878.41
| Facility | | $4,927.10 | $6,654.72 | $7,878.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.69 / $1,831.40 / $3,062.88
| Professional | | $1,556.69 | $1,831.40 | $3,062.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.73 / $2,479.82 / $2,479.82
| Facility | | $2,015.73 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $2,479.82 / $2,479.82
| Professional | | $1,810.27 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.34 / $2,066.78 / $2,897.61
| Professional | | $1,571.34 | $2,066.78 | $2,897.61 |