- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.40 / $1,563.43 / $1,563.43
| Professional | | $1,125.40 | $1,563.43 | $1,563.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.86 / $2,968.03 / $5,501.78
| Facility | | $2,290.86 | $2,968.03 | $5,501.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.64 / $1,232.76 / $1,232.76
| Professional | | $1,148.64 | $1,232.76 | $1,232.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.09 / $1,207.09 / $1,893.13
| Facility | | $1,207.09 | $1,207.09 | $1,893.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $881.18 / $1,207.09
| Professional | | $881.18 | $881.18 | $1,207.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.46 / $2,085.46 / $2,085.46
| Professional | | $2,085.46 | $2,085.46 | $2,085.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.31 / $1,563.43 / $1,563.43
| Professional | | $1,450.31 | $1,563.43 | $1,563.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.67 / $1,285.01 / $2,955.11
| Professional | | $856.67 | $1,285.01 | $2,955.11 |