- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,365.16
| Professional | | $1,778.28 | $2,344.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $2,951.21
| Professional | | $2,041.74 | $2,754.23 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,388.44
| Facility | | $2,951.21 | $3,019.95 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,388.44
| Professional | | $2,951.21 | $3,019.95 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,511.89 / $3,388.44
| Facility | | $1,548.82 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,819.70 / $3,630.78
| Professional | | $79.43 | $1,819.70 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,019.95 / $4,365.16
| Professional | | $2,570.40 | $3,019.95 | $4,365.16 |