- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $3,235.94
| Professional | | $1,318.26 | $1,778.28 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $2,187.76
| Professional | | $1,513.56 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,238.72 / $2,511.89
| Facility | | $2,187.76 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,238.72 / $2,511.89
| Professional | | $2,187.76 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $2,511.89
| Facility | | $1,174.90 | $1,905.46 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,348.96 / $2,691.53
| Professional | | $79.43 | $1,348.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $3,235.94
| Professional | | $1,949.84 | $2,238.72 | $3,235.94 |