- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.46 / $1,585.32 / $1,585.32
| Professional | | $1,028.46 | $1,585.32 | $1,585.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,093.52 / $2,712.35 / $5,027.84
| Facility | | $2,093.52 | $2,712.35 | $5,027.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.81 / $1,374.81 / $1,767.17
| Professional | | $1,374.81 | $1,374.81 | $1,767.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.19 / $1,346.19 / $1,730.06
| Facility | | $1,346.19 | $1,346.19 | $1,730.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.72 / $982.72 / $1,346.19
| Professional | | $982.72 | $982.72 | $1,346.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.81 / $1,905.81 / $1,905.81
| Professional | | $1,905.81 | $1,905.81 | $1,905.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.38 / $1,585.32 / $1,585.32
| Professional | | $1,325.38 | $1,585.32 | $1,585.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.88 / $1,417.54 / $2,700.55
| Professional | | $782.88 | $1,417.54 | $2,700.55 |