- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $5,754.40
| Professional | | $1,621.81 | $1,995.26 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,413.10 / $8,709.64
| Facility | | $5,370.32 | $7,413.10 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $3,981.07
| Professional | | $1,479.11 | $1,949.84 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,454.71
| Professional | | $1,778.28 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,630.27 / $4,677.35
| Facility | | $2,238.72 | $2,630.27 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $3,090.30
| Professional | | $1,659.59 | $2,137.96 | $3,090.30 |