- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $3,548.13
| Professional | | $1,288.25 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,819.70 / $2,238.72
| Professional | | $1,071.52 | $1,819.70 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,454.71 / $2,754.23
| Facility | | $2,238.72 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,454.71 / $2,754.23
| Professional | | $2,238.72 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,630.27
| Facility | | $1,288.25 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,819.70 / $2,818.38
| Professional | | $79.43 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,187.76 / $2,570.40
| Professional | | $1,737.80 | $2,187.76 | $2,570.40 |