- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.14 / $2,093.57 / $3,646.50
| Professional | | $1,648.14 | $2,093.57 | $3,646.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,306.23 / $3,306.23 / $3,306.23
| Facility | | $3,306.23 | $3,306.23 | $3,306.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.74 / $3,306.23 / $6,235.28
| Professional | | $2,047.74 | $3,306.23 | $6,235.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.02 / $1,929.92 / $4,185.34
| Facility | | $1,078.02 | $1,929.92 | $4,185.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.80 / $2,865.75 / $3,935.66
| Professional | | $1,105.80 | $2,865.75 | $3,935.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,964.38 / $3,578.20 / $4,377.47
| Professional | | $2,964.38 | $3,578.20 | $4,377.47 |