- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $5,888.44
| Professional | | $1,819.70 | $2,344.23 | $5,888.44 |
- 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
- $2,041.74 / $2,041.74 / $2,754.23
| Professional | | $2,041.74 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $3,388.44
| Facility | | $2,951.21 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $3,388.44
| Professional | | $2,951.21 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,951.21 / $3,235.94
| Facility | | $2,089.30 | $2,951.21 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,698.24 / $3,388.44
| Professional | | $79.43 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,090.30 / $4,786.30
| Professional | | $2,570.40 | $3,090.30 | $4,786.30 |