- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.16 / $2,224.32 / $2,477.53
| Professional | | $1,825.16 | $2,224.32 | $2,477.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,906.08 / $7,976.94 / $9,443.76
| Facility | | $5,906.08 | $7,976.94 | $9,443.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,999.27 / $2,352.08 / $3,777.56
| Professional | | $1,999.27 | $2,352.08 | $3,777.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.21 / $2,970.85 / $2,970.85
| Facility | | $2,416.21 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,970.85 / $2,970.85
| Professional | | $2,168.71 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.55 / $2,385.60 / $3,473.33
| Professional | | $1,883.55 | $2,385.60 | $3,473.33 |