- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $5,370.32
| Professional | | $2,290.87 | $3,019.95 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,388.44 / $3,715.35
| Professional | | $2,290.87 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,801.89 / $4,168.69
| Facility | | $3,715.35 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,801.89 / $4,168.69
| Professional | | $3,715.35 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,311.31 / $3,715.35
| Facility | | $1,905.46 | $3,311.31 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,290.87 / $4,570.88
| Professional | | $79.43 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,715.35 / $5,370.32
| Professional | | $2,951.21 | $3,715.35 | $5,370.32 |