- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $4,073.80
| Professional | | $1,621.81 | $2,187.76 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $2,818.38
| Professional | | $1,862.09 | $2,570.40 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,884.03 / $3,162.28
| Facility | | $2,818.38 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,884.03 / $3,162.28
| Professional | | $2,818.38 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,344.23 / $2,884.03
| Facility | | $1,445.44 | $2,344.23 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,698.24 / $3,388.44
| Professional | | $79.43 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $3,981.07
| Professional | | $2,290.87 | $2,754.23 | $3,981.07 |