- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $5,623.41
| Professional | | $1,819.70 | $2,511.89 | $5,623.41 |
- 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
- $2,238.72 / $2,238.72 / $2,951.21
| Professional | | $2,238.72 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,235.94 / $3,548.13
| Facility | | $3,162.28 | $3,235.94 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,235.94 / $3,548.13
| Professional | | $3,162.28 | $3,235.94 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $3,630.78
| Facility | | $2,238.72 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,778.28 / $3,630.78
| Professional | | $79.43 | $1,778.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $5,128.61
| Professional | | $2,818.38 | $3,311.31 | $5,128.61 |