- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.28 / $1,076.03 / $1,289.21
| Professional | | $1,025.28 | $1,076.03 | $1,289.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.04 / $1,306.04 / $1,967.58
| Facility | | $1,306.04 | $1,306.04 | $1,967.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,008.06 / $6,008.06 / $6,008.06
| Professional | | $6,008.06 | $6,008.06 | $6,008.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,223.19 / $4,242.64 / $5,969.94
| Facility | | $2,223.19 | $4,242.64 | $5,969.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.37 / $2,108.37 / $3,638.91
| Professional | | $2,108.37 | $2,108.37 | $3,638.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,584.90 / $2,584.90 / $2,584.90
| Professional | | $2,584.90 | $2,584.90 | $2,584.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,223.51 / $2,223.51 / $2,223.51
| Facility | | $2,223.51 | $2,223.51 | $2,223.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.92 / $1,903.69 / $2,487.94
| Professional | | $1,671.92 | $1,903.69 | $2,487.94 |