- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.57 / $1,736.55 / $1,736.55
| Professional | | $1,126.57 | $1,736.55 | $1,736.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,293.23 / $2,971.09 / $5,507.46
| Facility | | $2,293.23 | $2,971.09 | $5,507.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.71 / $1,234.04 / $1,935.74
| Professional | | $1,168.71 | $1,234.04 | $1,935.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.77 / $1,226.77 / $1,895.10
| Facility | | $1,226.77 | $1,226.77 | $1,895.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.54 / $895.54 / $1,226.77
| Professional | | $895.54 | $895.54 | $1,226.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.62 / $2,087.62 / $2,087.62
| Professional | | $2,087.62 | $2,087.62 | $2,087.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.81 / $1,736.55 / $1,736.55
| Professional | | $1,451.81 | $1,736.55 | $1,736.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.56 / $1,286.33 / $2,958.17
| Professional | | $857.56 | $1,286.33 | $2,958.17 |