- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.55 / $1,481.52 / $1,598.44
| Professional | | $1,177.55 | $1,481.52 | $1,598.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,810.46 / $5,146.52 / $6,092.87
| Facility | | $3,810.46 | $5,146.52 | $6,092.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.89 / $1,416.34 / $2,368.71
| Professional | | $1,203.89 | $1,416.34 | $2,368.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $1,786.24
| Facility | | $1,786.24 | $1,786.24 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,786.24 / $1,786.24
| Professional | | $1,303.96 | $1,786.24 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.22 / $1,717.90 / $2,240.91
| Professional | | $1,215.22 | $1,717.90 | $2,240.91 |