- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.25 / $2,061.98 / $2,061.98
| Professional | | $1,498.25 | $2,061.98 | $2,061.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,021.41 / $3,914.51 / $7,256.27
| Facility | | $3,021.41 | $3,914.51 | $7,256.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.25 / $2,060.17 / $2,060.17
| Professional | | $1,966.25 | $2,060.17 | $2,060.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,496.85
| Facility | | $2,017.28 | $2,017.28 | $2,496.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $1,472.61 / $2,017.28
| Professional | | $1,472.61 | $1,472.61 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,750.51 / $2,750.51 / $2,750.51
| Professional | | $2,750.51 | $2,750.51 | $2,750.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.80 / $2,061.98 / $2,061.98
| Professional | | $1,912.80 | $2,061.98 | $2,061.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.95 / $1,961.22 / $3,897.48
| Professional | | $1,240.95 | $1,961.22 | $3,897.48 |