- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $4,265.80
| Professional | | $1,548.82 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,344.23 / $2,884.03
| Professional | | $1,445.44 | $2,344.23 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,162.28
| Facility | | $2,884.03 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,162.28
| Professional | | $2,884.03 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $3,630.78
| Facility | | $1,698.24 | $2,511.89 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,344.23 / $3,467.37
| Professional | | $79.43 | $2,344.23 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $3,235.94
| Professional | | $2,187.76 | $2,818.38 | $3,235.94 |