- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.52 / $2,460.96 / $2,460.96
| Professional | | $1,596.52 | $2,460.96 | $2,460.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,249.86 / $4,210.49 / $7,804.92
| Facility | | $3,249.86 | $4,210.49 | $7,804.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.17 / $2,134.17 / $2,743.23
| Professional | | $2,134.17 | $2,134.17 | $2,743.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,685.64
| Facility | | $2,264.80 | $2,264.80 | $2,685.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $1,653.30 / $2,264.80
| Professional | | $1,653.30 | $1,653.30 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.47 / $2,958.47 / $2,958.47
| Professional | | $2,958.47 | $2,958.47 | $2,958.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.42 / $2,460.96 / $2,460.96
| Professional | | $2,057.42 | $2,460.96 | $2,460.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.53 / $2,513.88 / $4,192.17
| Professional | | $1,285.53 | $2,513.88 | $4,192.17 |