- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,995.26 / $5,128.61
| Professional | | $1,737.80 | $1,995.26 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $5,623.41
| Professional | | $1,819.70 | $2,570.40 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,235.94 / $3,548.13
| Facility | | $3,162.28 | $3,235.94 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,235.94 / $3,548.13
| Professional | | $3,162.28 | $3,235.94 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $4,677.35
| Facility | | $1,862.09 | $2,570.40 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,951.21 / $4,786.30
| Professional | | $79.43 | $2,951.21 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $3,890.45
| Professional | | $2,511.89 | $3,090.30 | $3,890.45 |