- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,630.78
| Professional | | $1,348.96 | $1,905.46 | $3,630.78 |
- 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
- $1,148.15 / $1,905.46 / $2,344.23
| Professional | | $1,148.15 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $2,570.40
| Facility | | $2,290.87 | $2,398.83 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $2,570.40
| Professional | | $2,290.87 | $2,398.83 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $2,818.38
| Facility | | $1,380.38 | $1,949.84 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,905.46 / $2,818.38
| Professional | | $79.43 | $1,905.46 | $2,818.38 |
- 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 |