- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.29 / $1,938.98 / $2,014.82
| Professional | | $1,484.29 | $1,938.98 | $2,014.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,803.04 / $6,487.16 / $7,680.04
| Facility | | $4,803.04 | $6,487.16 | $7,680.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.49 / $1,785.28 / $2,985.76
| Professional | | $1,517.49 | $1,785.28 | $2,985.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,964.96 / $2,017.28 / $2,017.28
| Facility | | $1,964.96 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $2,017.28 / $2,017.28
| Professional | | $1,472.61 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.05 / $1,694.79 / $2,824.65
| Professional | | $1,365.05 | $1,694.79 | $2,824.65 |