- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.63 / $2,347.06 / $2,347.06
| Professional | | $1,522.63 | $2,347.06 | $2,347.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,099.45 / $4,015.63 / $7,443.70
| Facility | | $3,099.45 | $4,015.63 | $7,443.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.20 / $1,982.76 / $2,616.28
| Professional | | $1,898.20 | $1,982.76 | $2,616.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,443.09 / $2,479.82 / $2,561.34
| Facility | | $2,443.09 | $2,479.82 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $1,810.27 / $2,479.82
| Professional | | $1,810.27 | $1,810.27 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,821.55 / $2,821.55 / $2,821.55
| Professional | | $2,821.55 | $2,821.55 | $2,821.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.21 / $2,347.06 / $2,347.06
| Professional | | $1,962.21 | $2,347.06 | $2,347.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.28 / $2,583.48 / $3,484.88
| Professional | | $1,361.28 | $2,583.48 | $3,484.88 |