- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $7,244.36
| Professional | | $1,380.38 | $2,238.72 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,265.80 / $4,897.79
| Facility | | $3,548.13 | $4,265.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,365.16
| Professional | | $3,548.13 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $7,244.36
| Professional | | $1,380.38 | $2,238.72 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,548.13 / $4,677.35
| Professional | | $1,548.82 | $3,548.13 | $4,677.35 |