- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,467.37 / $4,897.79
| Professional | | $1,548.82 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $2,187.76 / $5,248.07
| Professional | | $354.81 | $2,187.76 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,454.71 / $4,265.80
| Professional | | $1,548.82 | $2,454.71 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,677.35 / $4,786.30
| Professional | | $4,466.84 | $4,677.35 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $467.74 / $3,388.44
| Professional | | $346.74 | $467.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $1,548.82 / $3,548.13
| Facility | | $208.93 | $1,548.82 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,238.72 / $3,981.07
| Professional | | $346.74 | $2,238.72 | $3,981.07 |