- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $1,905.46
| Professional | | $1,479.11 | $1,819.70 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $5,888.44
| Facility | | $1,949.84 | $2,511.89 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $5,888.44
| Professional | | $1,949.84 | $2,511.89 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,818.38 / $4,265.80
| Facility | | $1,737.80 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,737.80 / $2,818.38
| Professional | | $79.43 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,949.84
| Professional | | $812.83 | $812.83 | $1,949.84 |