- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.55 / $1,387.39 / $1,507.49
| Professional | | $1,110.55 | $1,387.39 | $1,507.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,593.65 / $4,853.71 / $5,746.22
| Facility | | $3,593.65 | $4,853.71 | $5,746.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.49 / $1,431.17 / $2,298.53
| Professional | | $1,216.49 | $1,431.17 | $2,298.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.18 / $1,964.43 / $1,964.43
| Facility | | $1,470.18 | $1,964.43 | $1,964.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.03 / $1,964.43 / $1,964.43
| Professional | | $1,434.03 | $1,964.43 | $1,964.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.43 / $1,536.58 / $2,113.41
| Professional | | $1,152.43 | $1,536.58 | $2,113.41 |