- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $4,365.16
| Professional | | $1,096.48 | $1,513.56 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,623.41 / $6,606.93
| Facility | | $4,168.69 | $5,623.41 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $3,019.95
| Professional | | $1,122.02 | $1,513.56 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,949.84
| Facility | | $1,659.59 | $1,659.59 | $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
- $1,621.81 / $1,905.46 / $3,311.31
| Facility | | $1,621.81 | $1,905.46 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $2,344.23
| Professional | | $1,288.25 | $1,621.81 | $2,344.23 |