- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,311.31 / $4,265.80
| Professional | | $1,905.46 | $3,311.31 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $3,981.07
| Facility | | $3,311.31 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,388.44 / $3,981.07
| Professional | | $2,398.83 | $3,388.44 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,715.35 / $7,244.36
| Facility | | $2,951.21 | $3,715.35 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,715.35 / $7,244.36
| Professional | | $2,951.21 | $3,715.35 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $5,495.41
| Facility | | $2,041.74 | $3,890.45 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,311.31 / $4,897.79
| Professional | | $79.43 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $3,019.95
| Facility | | $2,511.89 | $2,884.03 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,905.46 / $2,951.21
| Professional | | $1,737.80 | $1,905.46 | $2,951.21 |