- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.58 / $1,838.86 / $1,983.99
| Professional | | $1,461.58 | $1,838.86 | $1,983.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,729.53 / $6,387.86 / $7,562.48
| Facility | | $4,729.53 | $6,387.86 | $7,562.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.17 / $2,184.90 / $3,025.05
| Professional | | $1,857.17 | $2,184.90 | $3,025.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,217.07
| Facility | | $2,217.07 | $2,217.07 | $2,217.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,217.07 / $2,217.07
| Professional | | $1,618.46 | $2,217.07 | $2,217.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.42 / $2,018.42 / $2,018.42
| Facility | | $2,018.42 | $2,018.42 | $2,018.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.33 / $2,036.58 / $2,781.42
| Professional | | $1,508.33 | $2,036.58 | $2,781.42 |