- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $4,466.84
| Professional | | $1,318.26 | $1,737.80 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $2,041.74
| Professional | | $1,584.89 | $1,584.89 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $2,570.40
| Facility | | $2,187.76 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $2,570.40
| Professional | | $2,187.76 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,187.76 / $2,570.40
| Facility | | $1,584.89 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,258.93 / $2,511.89
| Professional | | $79.43 | $1,258.93 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $3,548.13
| Professional | | $1,995.26 | $2,398.83 | $3,548.13 |