- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $3,715.35
| Professional | | $1,258.93 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,905.46 / $4,168.69
| Professional | | $1,380.38 | $1,905.46 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $2,691.53
| Facility | | $2,344.23 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $2,691.53
| Professional | | $2,344.23 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $3,388.44
| Facility | | $1,380.38 | $1,995.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,187.76 / $3,630.78
| Professional | | $79.43 | $2,187.76 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $2,818.38
| Professional | | $1,819.70 | $2,290.87 | $2,818.38 |