- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.08 / $2,666.38 / $2,666.38
| Professional | | $2,089.08 | $2,666.38 | $2,666.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,521.13 / $4,561.93 / $8,456.40
| Facility | | $3,521.13 | $4,561.93 | $8,456.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,739.20 / $2,739.20 / $3,043.56
| Professional | | $2,739.20 | $2,739.20 | $3,043.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $2,191.15 / $3,001.57
| Professional | | $2,191.15 | $2,191.15 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.42 / $3,205.42 / $3,205.42
| Professional | | $3,205.42 | $3,205.42 | $3,205.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.67 / $2,666.38 / $2,666.38
| Professional | | $2,282.67 | $2,666.38 | $2,666.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,357.69 / $4,542.10
| Professional | | $1,316.73 | $2,357.69 | $4,542.10 |