- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $4,265.80
| Professional | | $1,318.26 | $1,737.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,041.74
| Professional | | $1,380.38 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,238.72 / $2,454.71
| Facility | | $2,187.76 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,238.72 / $2,454.71
| Professional | | $2,187.76 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $2,344.23
| Facility | | $1,548.82 | $2,187.76 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,230.27 / $2,511.89
| Professional | | $79.43 | $1,230.27 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,548.13
| Professional | | $1,862.09 | $2,187.76 | $3,548.13 |