- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $6,165.95
| Professional | | $1,862.09 | $2,454.71 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,884.03
| Professional | | $2,137.96 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $3,467.37
| Facility | | $3,090.30 | $3,162.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $3,467.37
| Professional | | $3,090.30 | $3,162.28 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,090.30 / $3,162.28
| Facility | | $2,187.76 | $3,090.30 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,778.28 / $3,548.13
| Professional | | $79.43 | $1,778.28 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $5,011.87
| Professional | | $2,511.89 | $3,162.28 | $5,011.87 |