- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.86 / $1,977.03 / $1,977.03
| Professional | | $1,370.86 | $1,977.03 | $1,977.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.79 / $2,804.91 / $3,162.90
| Facility | | $2,162.79 | $2,804.91 | $3,162.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.28 / $1,706.47 / $2,500.17
| Professional | | $1,382.28 | $1,706.47 | $2,500.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.87 / $1,977.03 / $2,797.77
| Professional | | $1,502.87 | $1,977.03 | $2,797.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.43 / $1,629.01 / $2,534.73
| Professional | | $1,463.43 | $1,629.01 | $2,534.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.86 / $1,977.03 / $1,977.03
| Professional | | $1,370.86 | $1,977.03 | $1,977.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.05 / $1,642.85 / $2,534.73
| Professional | | $1,321.05 | $1,642.85 | $2,534.73 |