- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.83 / $1,523.40 / $1,643.63
| Professional | | $1,210.83 | $1,523.40 | $1,643.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,918.15 / $5,291.96 / $6,265.06
| Facility | | $3,918.15 | $5,291.96 | $6,265.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.92 / $1,456.38 / $2,435.66
| Professional | | $1,237.92 | $1,456.38 | $2,435.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.92 / $1,584.92 / $1,584.92
| Facility | | $1,584.92 | $1,584.92 | $1,584.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.99 / $1,584.92 / $1,584.92
| Professional | | $1,156.99 | $1,584.92 | $1,584.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.41 / $1,666.10 / $2,304.23
| Professional | | $1,265.41 | $1,666.10 | $2,304.23 |