- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.82 / $1,604.23 / $1,870.29
| Professional | | $1,377.82 | $1,604.23 | $1,870.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,458.49 / $6,021.78 / $7,129.09
| Facility | | $4,458.49 | $6,021.78 | $7,129.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.63 / $1,657.21 / $2,771.57
| Professional | | $1,408.63 | $1,657.21 | $2,771.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $2,373.71
| Facility | | $2,373.71 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,373.71 / $2,373.71
| Professional | | $2,017.65 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.81 / $1,776.73 / $2,622.02
| Professional | | $1,231.81 | $1,776.73 | $2,622.02 |