- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.72 / $6,309.71 / $6,309.71
| Professional | | $1,610.72 | $6,309.71 | $6,309.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,936.52 / $1,936.52 / $1,936.52
| Facility | | $1,936.52 | $1,936.52 | $1,936.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.17 / $1,936.52 / $2,059.69
| Professional | | $1,260.17 | $1,936.52 | $2,059.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $955.32 / $2,123.55 / $2,219.44
| Facility | | $955.32 | $2,123.55 | $2,219.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.69 / $1,775.71 / $2,561.30
| Professional | | $1,183.69 | $1,775.71 | $2,561.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,521.28 / $1,521.28 / $1,521.28
| Facility | | $1,521.28 | $1,521.28 | $1,521.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.54 / $2,103.34 / $3,384.56
| Professional | | $1,675.54 | $2,103.34 | $3,384.56 |