- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $3,801.89
| Professional | | $1,318.26 | $1,584.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $4,365.16
| Professional | | $1,318.26 | $1,905.46 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $2,818.38
| Facility | | $2,398.83 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $2,818.38
| Professional | | $2,398.83 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $3,548.13
| Facility | | $1,445.44 | $1,949.84 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,290.87 / $3,801.89
| Professional | | $79.43 | $2,290.87 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $3,019.95
| Professional | | $1,862.09 | $2,344.23 | $3,019.95 |