- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.52 / $2,008.64 / $2,167.15
| Professional | | $1,596.52 | $2,008.64 | $2,167.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,166.20 / $6,977.66 / $8,260.73
| Facility | | $5,166.20 | $6,977.66 | $8,260.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.62 / $2,386.61 / $3,304.35
| Professional | | $2,028.62 | $2,386.61 | $3,304.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,264.80
| Facility | | $2,264.80 | $2,264.80 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $2,264.80 / $2,264.80
| Professional | | $1,653.30 | $2,264.80 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.47 / $2,414.92 / $3,038.22
| Professional | | $1,668.47 | $2,414.92 | $3,038.22 |