- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,890.45
| Professional | | $1,819.70 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $4,073.80
| Facility | | $2,570.40 | $2,570.40 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $6,456.54
| Professional | | $2,570.40 | $4,570.88 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,248.07 / $6,025.60
| Professional | | $3,162.28 | $5,248.07 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,754.23 / $3,235.94
| Facility | | $2,691.53 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,548.13 / $5,623.41
| Professional | | $2,398.83 | $3,548.13 | $5,623.41 |