- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.74 / $2,042.88 / $2,204.11
| Professional | | $1,623.74 | $2,042.88 | $2,204.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,254.29 / $7,096.61 / $8,401.54
| Facility | | $5,254.29 | $7,096.61 | $8,401.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.06 / $1,953.01 / $3,266.26
| Professional | | $1,660.06 | $1,953.01 | $3,266.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,463.07
| Facility | | $2,463.07 | $2,463.07 | $2,463.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,463.07 / $2,463.07
| Professional | | $1,798.04 | $2,463.07 | $2,463.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.68 / $2,262.54 / $3,090.01
| Professional | | $1,675.68 | $2,262.54 | $3,090.01 |