- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $3,630.78
| Professional | | $1,288.25 | $1,819.70 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,041.74 / $2,454.71
| Professional | | $1,202.26 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $2,630.27
| Facility | | $2,398.83 | $2,454.71 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $2,630.27
| Professional | | $2,398.83 | $2,454.71 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $2,754.23
| Facility | | $1,445.44 | $1,995.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,905.46 / $2,951.21
| Professional | | $79.43 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $2,691.53
| Professional | | $1,819.70 | $2,290.87 | $2,691.53 |