- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $2,344.23
| Professional | | $1,862.09 | $2,290.87 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $4,786.30
| Facility | | $2,454.71 | $3,019.95 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $4,786.30
| Professional | | $2,454.71 | $3,019.95 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,548.13 / $5,370.32
| Facility | | $2,187.76 | $3,548.13 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $3,019.95 / $3,548.13
| Professional | | $85.11 | $3,019.95 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,454.71
| Professional | | $1,023.29 | $1,023.29 | $2,454.71 |