- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.10 / $1,677.53 / $1,677.53
| Professional | | $1,243.10 | $1,677.53 | $1,677.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,215.29 / $2,870.11 / $5,320.28
| Facility | | $2,215.29 | $2,870.11 | $5,320.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.04 / $1,442.56 / $1,869.95
| Professional | | $1,381.04 | $1,442.56 | $1,869.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,746.16 / $1,747.16 / $1,830.69
| Facility | | $1,746.16 | $1,747.16 | $1,830.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,275.43 / $1,747.16
| Professional | | $1,275.43 | $1,275.43 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.67 / $2,016.67 / $2,016.67
| Professional | | $2,016.67 | $2,016.67 | $2,016.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.46 / $1,677.53 / $1,677.53
| Professional | | $1,402.46 | $1,677.53 | $1,677.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.93 / $1,699.21 / $2,857.63
| Professional | | $868.93 | $1,699.21 | $2,857.63 |