- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $4,265.80
| Professional | | $1,621.81 | $2,187.76 | $4,265.80 |
- 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
- $1,659.59 / $2,754.23 / $2,951.21
| Professional | | $1,659.59 | $2,754.23 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,311.31
| Facility | | $2,884.03 | $3,019.95 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,311.31
| Professional | | $2,884.03 | $3,019.95 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,511.89 / $2,951.21
| Facility | | $1,584.89 | $2,511.89 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,659.59 / $3,548.13
| Professional | | $79.43 | $1,659.59 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $4,265.80
| Professional | | $2,290.87 | $2,884.03 | $4,265.80 |