- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $4,365.16
| Professional | | $1,862.09 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $2,884.03
| Professional | | $1,819.70 | $2,754.23 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,630.78
| Facility | | $2,951.21 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,630.78
| Professional | | $2,951.21 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,630.27 / $3,019.95
| Facility | | $1,584.89 | $2,630.27 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,819.70 / $3,630.78
| Professional | | $79.43 | $1,819.70 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $4,265.80
| Professional | | $2,290.87 | $2,884.03 | $4,265.80 |