- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,041.74
| Professional | | $1,096.48 | $1,479.11 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $2,290.87
| Facility | | $2,238.72 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $2,290.87
| Professional | | $2,238.72 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $2,089.30
| Facility | | $1,023.29 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,089.30 / $3,388.44
| Professional | | $79.43 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $3,715.35
| Professional | | $2,511.89 | $3,090.30 | $3,715.35 |