- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $5,370.32
| Professional | | $1,584.89 | $2,089.30 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,454.71
| Professional | | $1,995.26 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,691.53 / $3,019.95
| Facility | | $2,630.27 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,691.53 / $3,019.95
| Professional | | $2,630.27 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,162.28
| Facility | | $1,905.46 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,513.56 / $3,019.95
| Professional | | $79.43 | $1,513.56 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $4,265.80
| Professional | | $2,398.83 | $2,754.23 | $4,265.80 |