- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.75 / $1,935.78 / $1,961.14
| Professional | | $1,444.75 | $1,935.78 | $1,961.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,675.07 / $6,314.28 / $7,475.37
| Facility | | $4,675.07 | $6,314.28 | $7,475.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.71 / $1,737.71 / $2,906.19
| Professional | | $1,737.71 | $1,737.71 | $2,906.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,912.60 / $2,561.34 / $2,561.34
| Facility | | $1,912.60 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,561.34 / $2,561.34
| Professional | | $1,869.78 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.96 / $2,107.69 / $2,749.37
| Professional | | $1,490.96 | $2,107.69 | $2,749.37 |