- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $1,513.56
| Professional | | $1,202.26 | $1,348.96 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $2,187.76
| Professional | | $1,862.09 | $1,949.84 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,454.71
| Facility | | $2,344.23 | $2,344.23 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,454.71
| Professional | | $2,344.23 | $2,344.23 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $2,187.76
| Facility | | $1,348.96 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $2,187.76
| Professional | | $1,862.09 | $1,949.84 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $2,570.40
| Professional | | $1,737.80 | $2,290.87 | $2,570.40 |