- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.06 / $2,225.27 / $2,225.27
| Professional | | $1,607.06 | $2,225.27 | $2,225.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,938.61 / $3,807.25 / $7,057.43
| Facility | | $2,938.61 | $3,807.25 | $7,057.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.10 / $1,959.67 / $2,480.53
| Professional | | $1,876.10 | $1,959.67 | $2,480.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,316.31 / $2,571.77 / $2,571.77
| Facility | | $2,316.31 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $1,877.39 / $2,571.77
| Professional | | $1,877.39 | $1,877.39 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.14 / $2,675.14 / $2,675.14
| Professional | | $2,675.14 | $2,675.14 | $2,675.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.40 / $2,225.27 / $2,225.27
| Professional | | $1,860.40 | $2,225.27 | $2,225.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.90 / $2,308.31 / $3,790.69
| Professional | | $1,098.90 | $2,308.31 | $3,790.69 |