- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.71 / $1,654.37 / $1,939.37
| Professional | | $1,428.71 | $1,654.37 | $1,939.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,623.18 / $6,244.22 / $7,392.42
| Facility | | $4,623.18 | $6,244.22 | $7,392.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.40 / $2,135.76 / $2,957.02
| Professional | | $1,815.40 | $2,135.76 | $2,957.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,891.37 / $2,084.13 / $2,084.13
| Facility | | $1,891.37 | $2,084.13 | $2,084.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $2,084.13 / $2,084.13
| Professional | | $1,521.41 | $2,084.13 | $2,084.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.91 / $1,815.91 / $1,815.91
| Facility | | $1,815.91 | $1,815.91 | $1,815.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.42 / $1,867.41 / $2,718.87
| Professional | | $1,474.42 | $1,867.41 | $2,718.87 |