- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.27 / $1,209.58 / $1,592.62
| Professional | | $1,173.27 | $1,209.58 | $1,592.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,796.57 / $5,127.79 / $6,070.69
| Facility | | $3,796.57 | $5,127.79 | $6,070.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.90 / $1,753.90 / $2,428.31
| Professional | | $1,753.90 | $1,753.90 | $2,428.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $1,553.21
| Facility | | $1,544.16 | $1,544.16 | $1,553.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,544.16 / $1,544.16
| Professional | | $1,127.24 | $1,544.16 | $1,544.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.29 / $1,339.65 / $2,232.75
| Professional | | $912.29 | $1,339.65 | $2,232.75 |