- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $3,715.35
| Professional | | $1,380.38 | $1,949.84 | $3,715.35 |
- 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
- $1,348.96 / $1,905.46 / $2,290.87
| Professional | | $1,348.96 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,691.53
| Facility | | $2,398.83 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,691.53
| Professional | | $2,398.83 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $3,090.30
| Facility | | $1,380.38 | $2,137.96 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,905.46 / $2,884.03
| Professional | | $79.43 | $1,905.46 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $2,630.27
| Professional | | $1,778.28 | $2,290.87 | $2,630.27 |