- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,398.83 / $3,090.30
| Professional | | $1,096.48 | $2,398.83 | $3,090.30 |
- 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
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $3,630.78
| Facility | | $3,090.30 | $3,162.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $3,630.78
| Professional | | $3,090.30 | $3,162.28 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $3,090.30
| Facility | | $2,187.76 | $2,884.03 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,778.28 / $3,801.89
| Professional | | $79.43 | $1,778.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $4,677.35
| Professional | | $2,398.83 | $2,884.03 | $4,677.35 |