- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $3,890.45
| Professional | | $1,122.02 | $1,513.56 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $5,888.44
| Facility | | $3,715.35 | $5,011.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $2,691.53
| Professional | | $1,071.52 | $1,445.44 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,949.84
| Facility | | $1,479.11 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,949.84
| Professional | | $1,445.44 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $3,162.28
| Facility | | $1,513.56 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $2,089.30
| Professional | | $1,148.15 | $1,479.11 | $2,089.30 |