- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,235.94
| Professional | | $1,479.11 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $4,677.35
| Professional | | $2,290.87 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,890.45 / $4,073.80
| Professional | | $2,754.23 | $3,890.45 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,019.95
| Professional | | $2,754.23 | $2,754.23 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $1,584.89 / $4,168.69
| Facility | | $213.80 | $1,584.89 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $3,890.45
| Professional | | $1,445.44 | $2,089.30 | $3,890.45 |