- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.07 / $2,748.12 / $3,664.16
| Professional | | $1,987.07 | $2,748.12 | $3,664.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.12 / $3,248.38 / $3,248.38
| Professional | | $2,761.12 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.52 / $4,716.81 / $5,202.56
| Professional | | $2,766.52 | $4,716.81 | $5,202.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.69 / $3,392.54 / $3,769.49
| Professional | | $2,261.69 | $3,392.54 | $3,769.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.19 / $2,596.26 / $3,768.22
| Professional | | $2,051.19 | $2,596.26 | $3,768.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,769.49 / $3,769.49 / $3,769.49
| Professional | | $3,769.49 | $3,769.49 | $3,769.49 |