- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,951.21 / $5,011.87
| Professional | | $1,905.46 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,311.31 / $3,630.78
| Professional | | $2,187.76 | $3,311.31 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,630.78 / $4,073.80
| Facility | | $3,548.13 | $3,630.78 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,630.78 / $4,073.80
| Professional | | $3,548.13 | $3,630.78 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,019.95 / $3,548.13
| Facility | | $1,905.46 | $3,019.95 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,187.76 / $4,365.16
| Professional | | $79.43 | $2,187.76 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $5,128.61
| Professional | | $2,818.38 | $3,548.13 | $5,128.61 |