- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.57 / $1,161.45 / $1,529.23
| Professional | | $1,126.57 | $1,161.45 | $1,529.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,645.49 / $4,923.71 / $5,829.10
| Facility | | $3,645.49 | $4,923.71 | $5,829.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.77 / $1,355.02 / $2,266.17
| Professional | | $1,151.77 | $1,355.02 | $2,266.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.77 / $1,226.77 / $1,491.40
| Facility | | $1,226.77 | $1,226.77 | $1,491.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.54 / $1,226.77 / $1,226.77
| Professional | | $895.54 | $1,226.77 | $1,226.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.60 / $1,451.81 / $2,143.89
| Professional | | $1,162.60 | $1,451.81 | $2,143.89 |