- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $3,981.07
| Professional | | $1,513.56 | $1,949.84 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,137.96 / $2,630.27
| Professional | | $1,288.25 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,691.53 / $3,235.94
| Facility | | $2,630.27 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,691.53 / $3,235.94
| Professional | | $2,630.27 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $3,019.95
| Facility | | $1,513.56 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,137.96 / $3,162.28
| Professional | | $79.43 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,570.40 / $2,951.21
| Professional | | $1,949.84 | $2,570.40 | $2,951.21 |