- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.45 / $1,966.16 / $2,018.19
| Professional | | $1,448.45 | $1,966.16 | $2,018.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,687.06 / $6,330.47 / $7,494.53
| Facility | | $4,687.06 | $6,330.47 | $7,494.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.84 / $1,742.17 / $2,913.64
| Professional | | $1,480.84 | $1,742.17 | $2,913.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,917.50 / $2,637.76 / $2,637.76
| Facility | | $1,917.50 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $2,637.76
| Professional | | $1,925.56 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.77 / $2,038.83 / $2,756.43
| Professional | | $1,556.77 | $2,038.83 | $2,756.43 |