- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,884.03
| Professional | | $1,122.02 | $1,348.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,344.23
| Facility | | $1,949.84 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,344.23
| Professional | | $1,949.84 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $2,041.74
| Facility | | $1,202.26 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $85.11 / $2,187.76
| Professional | | $79.43 | $85.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,290.87
| Professional | | $1,698.24 | $1,905.46 | $2,290.87 |