- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $4,677.35
| Professional | | $1,905.46 | $2,454.71 | $4,677.35 |
- 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
- $2,187.76 / $2,951.21 / $3,162.28
| Professional | | $2,187.76 | $2,951.21 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,630.78
| Facility | | $3,235.94 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,630.78
| Professional | | $3,235.94 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,754.23 / $3,630.78
| Facility | | $1,659.59 | $2,754.23 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,949.84 / $3,890.45
| Professional | | $79.43 | $1,949.84 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,235.94 / $4,677.35
| Professional | | $2,818.38 | $3,235.94 | $4,677.35 |