- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $4,786.30
| Professional | | $1,412.54 | $1,905.46 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,187.76
| Professional | | $1,819.70 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $2,951.21
| Facility | | $2,398.83 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $2,951.21
| Professional | | $2,398.83 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $2,818.38
| Facility | | $1,698.24 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,348.96 / $2,754.23
| Professional | | $79.43 | $1,348.96 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,890.45
| Professional | | $2,187.76 | $2,511.89 | $3,890.45 |