- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.45 / $2,232.71 / $2,232.71
| Professional | | $1,448.45 | $2,232.71 | $2,232.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,948.43 / $3,819.97 / $7,081.01
| Facility | | $2,948.43 | $3,819.97 | $7,081.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.27 / $2,115.48 / $2,488.81
| Professional | | $2,025.27 | $2,115.48 | $2,488.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,324.05 / $2,637.76 / $2,637.76
| Facility | | $2,324.05 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $1,925.56 / $2,637.76
| Professional | | $1,925.56 | $1,925.56 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,684.08 / $2,684.08 / $2,684.08
| Professional | | $2,684.08 | $2,684.08 | $2,684.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.61 / $2,232.71 / $2,232.71
| Professional | | $1,866.61 | $2,232.71 | $2,232.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.57 / $1,653.86 / $3,934.52
| Professional | | $1,102.57 | $1,653.86 | $3,934.52 |