- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,511.89 / $5,888.44
| Professional | | $1,659.59 | $2,511.89 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,585.78 / $8,912.51
| Facility | | $5,623.41 | $7,585.78 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $4,073.80
| Professional | | $1,513.56 | $1,995.26 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,311.31
| Facility | | $2,187.76 | $2,187.76 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,311.31
| Professional | | $2,398.83 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,951.21 / $5,248.07
| Facility | | $2,511.89 | $2,951.21 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,162.28
| Professional | | $1,778.28 | $2,398.83 | $3,162.28 |