- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,995.26 / $3,162.28
| Professional | | $1,584.89 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,884.03
| Facility | | $2,290.87 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $4,570.88
| Professional | | $2,290.87 | $3,235.94 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,890.45
| Professional | | $3,715.35 | $3,715.35 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $4,265.80
| Professional | | $2,238.72 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,238.72 / $2,630.27
| Facility | | $2,187.76 | $2,238.72 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $3,981.07
| Professional | | $1,949.84 | $2,754.23 | $3,981.07 |