- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $4,897.79
| Professional | | $1,479.11 | $1,949.84 | $4,897.79 |
- 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
- $2,454.71 / $2,511.89 / $2,754.23
| Facility | | $2,454.71 | $2,511.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,511.89 / $2,754.23
| Professional | | $2,454.71 | $2,511.89 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $2,691.53
| Facility | | $1,737.80 | $2,454.71 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,380.38 / $2,818.38
| Professional | | $79.43 | $1,380.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $3,981.07
| Professional | | $2,089.30 | $2,511.89 | $3,981.07 |