- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.88 / $1,602.97 / $1,623.99
| Professional | | $1,180.88 | $1,602.97 | $1,623.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,821.23 / $5,161.04 / $6,110.07
| Facility | | $3,821.23 | $5,161.04 | $6,110.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.30 / $1,420.35 / $2,375.41
| Professional | | $1,207.30 | $1,420.35 | $2,375.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $2,283.76 / $2,283.76
| Professional | | $1,667.14 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.66 / $1,782.40 / $2,247.23
| Professional | | $1,218.66 | $1,782.40 | $2,247.23 |