- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.28 / $1,357.70 / $1,477.26
| Professional | | $1,088.28 | $1,357.70 | $1,477.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,521.59 / $4,756.37 / $5,630.98
| Facility | | $3,521.59 | $4,756.37 | $5,630.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.96 / $1,308.96 / $2,189.15
| Professional | | $1,308.96 | $1,308.96 | $2,189.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.71 / $1,747.16 / $1,747.16
| Facility | | $1,440.71 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $1,747.16
| Professional | | $1,275.43 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.08 / $1,503.70 / $2,071.03
| Professional | | $1,123.08 | $1,503.70 | $2,071.03 |