- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $4,365.16
| Professional | | $1,737.80 | $2,290.87 | $4,365.16 |
- 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
- $2,041.74 / $2,754.23 / $3,019.95
| Professional | | $2,041.74 | $2,754.23 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $3,388.44
| Facility | | $2,951.21 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $3,388.44
| Professional | | $2,951.21 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $3,162.28
| Facility | | $1,513.56 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,819.70 / $3,630.78
| Professional | | $79.43 | $1,819.70 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $4,365.16
| Professional | | $2,454.71 | $2,951.21 | $4,365.16 |