- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.45 / $1,275.75 / $1,679.75
| Professional | | $1,237.45 | $1,275.75 | $1,679.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,004.26 / $5,408.29 / $6,402.78
| Facility | | $4,004.26 | $5,408.29 | $6,402.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.37 / $1,849.85 / $2,561.16
| Professional | | $1,572.37 | $1,849.85 | $2,561.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.28 / $1,327.28 / $1,327.28
| Facility | | $1,327.28 | $1,327.28 | $1,327.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.91 / $1,327.28 / $1,327.28
| Professional | | $968.91 | $1,327.28 | $1,327.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,832.16 / $2,832.16 / $2,832.16
| Facility | | $2,832.16 | $2,832.16 | $2,832.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.96 / $1,412.93 / $2,354.89
| Professional | | $941.96 | $1,412.93 | $2,354.89 |