- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $3,630.78
| Professional | | $1,148.15 | $1,380.38 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $5,495.41
| Facility | | $3,467.37 | $4,677.35 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $2,511.89
| Professional | | $933.25 | $1,230.27 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,819.70
| Facility | | $1,380.38 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,819.70
| Professional | | $1,318.26 | $1,318.26 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $3,162.28
| Facility | | $1,548.82 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $1,949.84
| Professional | | $1,096.48 | $1,479.11 | $1,949.84 |