- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.01 / $1,675.42 / $1,988.66
| Professional | | $1,465.01 | $1,675.42 | $1,988.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,740.66 / $6,402.90 / $7,580.28
| Facility | | $4,740.66 | $6,402.90 | $7,580.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.04 / $2,190.04 / $3,032.16
| Professional | | $2,190.04 | $2,190.04 | $3,032.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $1,937.73
| Facility | | $1,743.07 | $1,743.07 | $1,937.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $1,272.44
| Professional | | $1,272.44 | $1,272.44 | $1,272.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.89 / $1,914.86 / $2,787.96
| Professional | | $1,511.89 | $1,914.86 | $2,787.96 |