- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.96 / $1,919.04 / $1,919.04
| Professional | | $1,244.96 | $1,919.04 | $1,919.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,534.21 / $3,283.32 / $6,086.23
| Facility | | $2,534.21 | $3,283.32 | $6,086.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.84 / $1,567.70 / $2,139.17
| Professional | | $1,500.84 | $1,567.70 | $2,139.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.76 / $1,960.76 / $2,094.26
| Facility | | $1,960.76 | $1,960.76 | $2,094.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,431.35 / $1,960.76
| Professional | | $1,431.35 | $1,431.35 | $1,960.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.00 / $2,307.00 / $2,307.00
| Professional | | $2,307.00 | $2,307.00 | $2,307.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.39 / $1,919.04 / $1,919.04
| Professional | | $1,604.39 | $1,919.04 | $1,919.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.68 / $1,421.51 / $3,945.41
| Professional | | $947.68 | $1,421.51 | $3,945.41 |