- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $2,511.89
| Professional | | $1,949.84 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Professional | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $7,762.47
| Facility | | $2,570.40 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $7,762.47
| Professional | | $2,570.40 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,715.35 / $5,623.41
| Facility | | $2,290.87 | $3,715.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,290.87 / $3,715.35
| Professional | | $79.43 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $2,570.40
| Professional | | $1,071.52 | $1,071.52 | $2,570.40 |