- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.71 / $2,242.36 / $2,242.36
| Professional | | $1,454.71 | $2,242.36 | $2,242.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,961.19 / $3,836.49 / $7,111.64
| Facility | | $2,961.19 | $3,836.49 | $7,111.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.67 / $1,883.48 / $2,499.57
| Professional | | $1,790.67 | $1,883.48 | $2,499.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,578.56 / $2,253.75 / $2,447.07
| Facility | | $1,578.56 | $2,253.75 | $2,447.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $1,915.69 / $2,253.75
| Professional | | $1,915.69 | $1,915.69 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.68 / $2,695.68 / $2,695.68
| Professional | | $2,695.68 | $2,695.68 | $2,695.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.68 / $2,242.36 / $2,242.36
| Professional | | $1,874.68 | $2,242.36 | $2,242.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.33 / $1,942.23 / $3,819.81
| Professional | | $1,107.33 | $1,942.23 | $3,819.81 |