- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.68 / $1,255.38 / $1,652.91
| Professional | | $1,217.68 | $1,255.38 | $1,652.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.31 / $5,321.90 / $6,300.50
| Facility | | $3,940.31 | $5,321.90 | $6,300.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.25 / $1,820.29 / $2,520.23
| Professional | | $1,547.25 | $1,820.29 | $2,520.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.07 / $1,306.07 / $1,612.01
| Facility | | $1,306.07 | $1,306.07 | $1,612.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.43 / $1,306.07 / $1,306.07
| Professional | | $953.43 | $1,306.07 | $1,306.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.83 / $1,390.36 / $2,317.27
| Professional | | $946.83 | $1,390.36 | $2,317.27 |