- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $4,786.30
| Professional | | $1,445.44 | $1,905.46 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,238.72
| Professional | | $1,659.59 | $1,659.59 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $2,691.53
| Facility | | $2,398.83 | $2,454.71 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $2,691.53
| Professional | | $2,398.83 | $2,454.71 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $2,691.53
| Facility | | $1,698.24 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,380.38 / $2,754.23
| Professional | | $79.43 | $1,380.38 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $3,890.45
| Professional | | $2,089.30 | $2,454.71 | $3,890.45 |