- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $2,884.03
| Professional | | $1,023.29 | $1,202.26 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $3,311.31
| Professional | | $1,096.48 | $1,548.82 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,949.84 / $2,137.96
| Facility | | $1,905.46 | $1,949.84 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,949.84 / $2,137.96
| Professional | | $1,905.46 | $1,949.84 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,818.38
| Facility | | $1,096.48 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,737.80 / $2,884.03
| Professional | | $79.43 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $2,344.23
| Professional | | $1,479.11 | $1,905.46 | $2,344.23 |