- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.42 / $1,848.76 / $2,080.80
| Professional | | $1,546.42 | $1,848.76 | $2,080.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.26 / $2,976.51 / $5,517.50
| Facility | | $2,510.26 | $2,976.51 | $5,517.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.40 / $1,615.40 / $1,901.61
| Professional | | $1,615.40 | $1,615.40 | $1,901.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,414.94 / $1,460.50 / $2,520.11
| Facility | | $1,414.94 | $1,460.50 | $2,520.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $1,825.63
| Professional | | $1,241.43 | $1,460.50 | $1,825.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.40 / $2,106.40 / $2,106.40
| Professional | | $2,106.40 | $2,106.40 | $2,106.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.14 / $1,848.76 / $2,080.80
| Professional | | $707.14 | $1,848.76 | $2,080.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.12 / $1,288.68 / $2,963.55
| Professional | | $859.12 | $1,288.68 | $2,963.55 |