- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $5,888.44
| Professional | | $1,659.59 | $2,089.30 | $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
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,511.89
| Professional | | $1,862.09 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $4,786.30
| Facility | | $2,290.87 | $2,691.53 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $3,162.28
| Professional | | $1,737.80 | $2,238.72 | $3,162.28 |