- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.66 / $2,106.94 / $2,273.23
| Professional | | $1,674.66 | $2,106.94 | $2,273.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,419.04 / $7,319.12 / $8,664.98
| Facility | | $5,419.04 | $7,319.12 | $8,664.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.11 / $2,014.25 / $3,368.67
| Professional | | $1,712.11 | $2,014.25 | $3,368.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $2,540.30
| Facility | | $2,540.30 | $2,540.30 | $2,540.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $2,540.30 / $2,540.30
| Professional | | $1,854.42 | $2,540.30 | $2,540.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.23 / $2,443.10 / $3,186.91
| Professional | | $1,728.23 | $2,443.10 | $3,186.91 |