- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.10 / $1,966.59 / $2,366.12
| Professional | | $1,743.10 | $1,966.59 | $2,366.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,640.51 / $7,618.26 / $9,019.12
| Facility | | $5,640.51 | $7,618.26 | $9,019.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.08 / $2,096.56 / $3,506.36
| Professional | | $1,782.08 | $2,096.56 | $3,506.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,307.57 / $2,694.60 / $2,694.60
| Facility | | $2,307.57 | $2,694.60 | $2,694.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $1,967.06
| Professional | | $1,967.06 | $1,967.06 | $1,967.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.85 / $2,278.33 / $3,317.16
| Professional | | $1,798.85 | $2,278.33 | $3,317.16 |