- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,754.23
| Professional | | $1,096.48 | $1,445.44 | $2,754.23 |
- 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
- $1,258.93 / $1,737.80 / $1,862.09
| Professional | | $1,258.93 | $1,737.80 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,905.46 / $2,089.30
| Facility | | $1,862.09 | $1,905.46 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,905.46 / $2,089.30
| Professional | | $1,862.09 | $1,905.46 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,584.89 / $2,089.30
| Facility | | $977.24 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,122.02 / $2,238.72
| Professional | | $79.43 | $1,122.02 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $2,754.23
| Professional | | $1,584.89 | $1,862.09 | $2,754.23 |