- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.63 / $1,367.95 / $1,500.82
| Professional | | $1,105.63 | $1,367.95 | $1,500.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,577.73 / $4,832.20 / $5,720.76
| Facility | | $3,577.73 | $4,832.20 | $5,720.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.35 / $1,329.84 / $2,224.05
| Professional | | $1,130.35 | $1,329.84 | $2,224.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.68 / $1,703.99 / $1,703.99
| Facility | | $1,463.68 | $1,703.99 | $1,703.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.91 / $1,703.99 / $1,703.99
| Professional | | $1,243.91 | $1,703.99 | $1,703.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.47 / $1,352.64 / $2,104.05
| Professional | | $988.47 | $1,352.64 | $2,104.05 |