- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.43 / $1,619.76 / $1,747.60
| Professional | | $1,287.43 | $1,619.76 | $1,747.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,166.01 / $5,626.75 / $6,661.41
| Facility | | $4,166.01 | $5,626.75 | $6,661.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.23 / $1,548.50 / $2,589.75
| Professional | | $1,316.23 | $1,548.50 | $2,589.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $1,952.91
| Facility | | $1,952.91 | $1,952.91 | $1,952.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,952.91 / $1,952.91
| Professional | | $1,425.62 | $1,952.91 | $1,952.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.62 / $1,793.93 / $2,450.01
| Professional | | $1,328.62 | $1,793.93 | $2,450.01 |