- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $5,370.32
| Professional | | $1,513.56 | $1,905.46 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,918.31 / $8,128.31
| Facility | | $5,128.61 | $6,918.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $3,715.35
| Professional | | $1,380.38 | $1,819.70 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,454.71
| Facility | | $1,995.26 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,454.71
| Professional | | $1,819.70 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $4,265.80
| Facility | | $2,041.74 | $2,398.83 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,995.26 / $2,884.03
| Professional | | $1,584.89 | $1,995.26 | $2,884.03 |