- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.35 / $2,573.29 / $2,605.86
| Professional | | $1,625.35 | $2,573.29 | $2,605.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,259.51 / $7,103.65 / $8,409.89
| Facility | | $5,259.51 | $7,103.65 | $8,409.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.20 / $2,017.88 / $3,287.53
| Professional | | $1,715.20 | $2,017.88 | $3,287.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.66 / $2,381.07 / $2,381.07
| Facility | | $274.66 | $2,381.07 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $2,381.07 / $2,381.07
| Professional | | $1,738.18 | $2,381.07 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.11 / $2,124.42 / $3,093.08
| Professional | | $1,453.11 | $2,124.42 | $3,093.08 |