- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $4,265.80
| Professional | | $2,344.23 | $3,467.37 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,011.87 / $5,011.87
| Facility | | $2,818.38 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,073.80 / $5,011.87
| Professional | | $2,398.83 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,570.88 / $8,912.51
| Facility | | $3,630.78 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,570.88 / $8,912.51
| Professional | | $3,630.78 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,365.16 / $6,918.31
| Facility | | $2,511.89 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $3,715.35 / $5,011.87
| Professional | | $79.43 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,951.21 / $3,548.13
| Facility | | $1,174.90 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $3,467.37
| Professional | | $2,041.74 | $2,238.72 | $3,467.37 |