- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.71 / $1,772.69 / $1,974.66
| Professional | | $1,454.71 | $1,772.69 | $1,974.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,707.32 / $6,357.87 / $7,526.97
| Facility | | $4,707.32 | $6,357.87 | $7,526.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.25 / $1,749.70 / $2,926.25
| Professional | | $1,487.25 | $1,749.70 | $2,926.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $2,253.75
| Facility | | $2,253.75 | $2,253.75 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $2,253.75 / $2,253.75
| Professional | | $1,915.69 | $2,253.75 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.05 / $1,963.30 / $2,768.35
| Professional | | $1,435.05 | $1,963.30 | $2,768.35 |