- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.62 / $1,844.39 / $1,967.69
| Professional | | $1,443.62 | $1,844.39 | $1,967.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,671.43 / $6,309.39 / $7,469.58
| Facility | | $4,671.43 | $6,309.39 | $7,469.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.37 / $1,736.37 / $2,903.94
| Professional | | $1,736.37 | $1,736.37 | $2,903.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,911.12 / $2,571.77 / $2,571.77
| Facility | | $1,911.12 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,571.77 / $2,571.77
| Professional | | $1,877.39 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.03 / $1,943.84 / $2,747.25
| Professional | | $1,532.03 | $1,943.84 | $2,747.25 |