- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.10 / $1,399.66 / $1,401.07
| Professional | | $1,031.10 | $1,399.66 | $1,401.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,336.59 / $4,506.46 / $5,335.13
| Facility | | $3,336.59 | $4,506.46 | $5,335.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.17 / $1,240.20 / $2,074.13
| Professional | | $1,054.17 | $1,240.20 | $2,074.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.02 / $1,823.10 / $1,823.10
| Facility | | $1,365.02 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $1,823.10
| Professional | | $1,330.86 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.22 / $1,504.26 / $1,962.22
| Professional | | $1,108.22 | $1,504.26 | $1,962.22 |