- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $5,011.87
| Professional | | $1,949.84 | $2,398.83 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,265.80 / $5,754.40
| Facility | | $3,548.13 | $4,265.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $3,890.45
| Professional | | $1,819.70 | $2,630.27 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,398.83 / $4,466.84
| Professional | | $457.09 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,819.70 / $5,370.32
| Facility | | $660.69 | $1,819.70 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $3,235.94
| Professional | | $1,819.70 | $2,238.72 | $3,235.94 |