- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.16 / $1,518.62 / $1,518.62
| Professional | | $1,093.16 | $1,518.62 | $1,518.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.21 / $2,882.97 / $5,344.12
| Facility | | $2,225.21 | $2,882.97 | $5,344.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.53 / $1,197.44 / $1,197.44
| Professional | | $1,130.53 | $1,197.44 | $1,197.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $1,838.89
| Facility | | $1,172.51 | $1,172.51 | $1,838.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $855.93 / $1,172.51
| Professional | | $855.93 | $855.93 | $1,172.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.70 / $2,025.70 / $2,025.70
| Professional | | $2,025.70 | $2,025.70 | $2,025.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.75 / $1,518.62 / $1,518.62
| Professional | | $1,408.75 | $1,518.62 | $1,518.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.12 / $1,248.18 / $3,464.32
| Professional | | $832.12 | $1,248.18 | $3,464.32 |