- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.83 / $1,341.83 / $2,385.63
| Professional | | $1,341.83 | $1,341.83 | $2,385.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.40 / $2,168.01 / $4,018.80
| Facility | | $1,828.40 | $2,168.01 | $4,018.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.46 / $1,393.46 / $1,468.86
| Professional | | $1,393.46 | $1,393.46 | $1,468.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,559.34
| Facility | | $1,217.05 | $1,217.05 | $1,559.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.49 / $1,217.05 / $1,455.57
| Professional | | $1,034.49 | $1,217.05 | $1,455.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.50 / $1,503.50 / $1,503.50
| Professional | | $1,503.50 | $1,503.50 | $1,503.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.22 / $1,341.83 / $2,385.63
| Professional | | $1,055.22 | $1,341.83 | $2,385.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.61 / $1,230.08 / $3,152.80
| Professional | | $668.61 | $1,230.08 | $3,152.80 |