- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.19 / $2,284.62 / $2,284.62
| Professional | | $1,799.19 | $2,284.62 | $2,284.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,347.63 / $4,337.17 / $8,039.73
| Facility | | $3,347.63 | $4,337.17 | $8,039.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.37 / $2,198.38 / $2,198.38
| Professional | | $2,048.37 | $2,198.38 | $2,198.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,766.42
| Facility | | $2,326.75 | $2,326.75 | $2,766.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $1,698.53 / $2,326.75
| Professional | | $1,698.53 | $1,698.53 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,047.47 / $3,047.47 / $3,047.47
| Professional | | $3,047.47 | $3,047.47 | $3,047.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,069.05 / $2,284.62 / $2,284.62
| Professional | | $2,069.05 | $2,284.62 | $2,284.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.84 / $1,877.77 / $4,318.27
| Professional | | $1,251.84 | $1,877.77 | $4,318.27 |