- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $4,265.80
| Professional | | $1,202.26 | $1,513.56 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,495.41 / $6,456.54
| Facility | | $4,073.80 | $5,495.41 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,951.21
| Professional | | $1,096.48 | $1,445.44 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,584.89
| Professional | | $1,148.15 | $1,148.15 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $3,467.37
| Facility | | $1,659.59 | $1,949.84 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,659.59 / $2,290.87
| Professional | | $1,258.93 | $1,659.59 | $2,290.87 |