- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.60 / $1,222.46 / $1,545.59
| Professional | | $1,138.60 | $1,222.46 | $1,545.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,684.44 / $4,976.32 / $5,891.37
| Facility | | $3,684.44 | $4,976.32 | $5,891.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.51 / $1,369.51 / $2,290.38
| Professional | | $1,369.51 | $1,369.51 | $2,290.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,271.83 / $1,507.35
| Facility | | $1,271.83 | $1,271.83 | $1,507.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $1,271.83 / $1,271.83
| Professional | | $928.44 | $1,271.83 | $1,271.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.04 / $1,488.23 / $2,166.80
| Professional | | $1,175.04 | $1,488.23 | $2,166.80 |