- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.85 / $2,301.15 / $2,301.15
| Professional | | $1,492.85 | $2,301.15 | $2,301.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.82 / $3,937.07 / $7,298.09
| Facility | | $3,038.82 | $3,937.07 | $7,298.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.10 / $1,846.73 / $2,565.12
| Professional | | $1,738.10 | $1,846.73 | $2,565.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,619.96 / $1,808.29 / $2,511.26
| Facility | | $1,619.96 | $1,808.29 | $2,511.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $1,808.29
| Professional | | $1,537.05 | $1,537.05 | $1,808.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.35 / $2,766.35 / $2,766.35
| Professional | | $2,766.35 | $2,766.35 | $2,766.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.84 / $2,301.15 / $2,301.15
| Professional | | $1,923.84 | $2,301.15 | $2,301.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.36 / $1,704.56 / $3,919.96
| Professional | | $1,136.36 | $1,704.56 | $3,919.96 |