- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.96 / $1,475.48 / $1,689.95
| Professional | | $1,244.96 | $1,475.48 | $1,689.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,028.60 / $5,441.14 / $6,441.67
| Facility | | $4,028.60 | $5,441.14 | $6,441.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.82 / $1,497.43 / $2,504.32
| Professional | | $1,272.82 | $1,497.43 | $2,504.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.14 / $1,960.76 / $1,960.76
| Facility | | $1,648.14 | $1,960.76 | $1,960.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,960.76 / $1,960.76
| Professional | | $1,431.35 | $1,960.76 | $1,960.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.79 / $1,627.24 / $2,369.19
| Professional | | $1,284.79 | $1,627.24 | $2,369.19 |