- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.97 / $1,896.54 / $2,193.55
| Professional | | $1,615.97 | $1,896.54 | $2,193.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,229.13 / $7,062.62 / $8,361.32
| Facility | | $5,229.13 | $7,062.62 | $8,361.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.65 / $1,943.65 / $3,250.62
| Professional | | $1,943.65 | $1,943.65 | $3,250.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,139.27 / $2,425.11 / $2,425.11
| Facility | | $2,139.27 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,425.11 / $2,425.11
| Professional | | $1,770.33 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.66 / $2,112.16 / $3,075.22
| Professional | | $1,667.66 | $2,112.16 | $3,075.22 |