- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $7,244.36
| Professional | | $1,905.46 | $2,570.40 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,951.21
| Professional | | $2,187.76 | $2,187.76 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,311.31 / $3,630.78
| Facility | | $3,235.94 | $3,311.31 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,311.31 / $3,630.78
| Professional | | $3,235.94 | $3,311.31 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $3,630.78
| Facility | | $2,290.87 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,819.70 / $3,715.35
| Professional | | $79.43 | $1,819.70 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,311.31 / $5,248.07
| Professional | | $2,884.03 | $3,311.31 | $5,248.07 |