- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.80 / $2,564.66 / $2,564.66
| Professional | | $1,663.80 | $2,564.66 | $2,564.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,386.80 / $4,387.91 / $8,133.80
| Facility | | $3,386.80 | $4,387.91 | $8,133.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.30 / $1,822.51 / $2,858.84
| Professional | | $1,715.30 | $1,822.51 | $2,858.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,798.81
| Facility | | $2,050.41 | $2,050.41 | $2,798.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $2,050.41
| Professional | | $1,496.80 | $1,496.80 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,083.14 / $3,083.14 / $3,083.14
| Professional | | $3,083.14 | $3,083.14 | $3,083.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,144.13 / $2,564.66 / $2,564.66
| Professional | | $2,144.13 | $2,564.66 | $2,564.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.50 / $1,899.75 / $4,368.84
| Professional | | $1,266.50 | $1,899.75 | $4,368.84 |