- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.92 / $1,932.36 / $7,750.21
| Professional | | $1,353.92 | $1,932.36 | $7,750.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $2,273.92
| Professional | | $1,786.79 | $1,786.79 | $2,273.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.64 / $466.21 / $3,688.32
| Professional | | $248.64 | $466.21 | $3,688.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $865.13 / $1,481.64 / $2,248.01
| Facility | | $865.13 | $1,481.64 | $2,248.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $2,273.92
| Professional | | $1,786.79 | $1,786.79 | $2,273.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.77 / $1,340.09 / $2,018.65
| Professional | | $1,135.77 | $1,340.09 | $2,018.65 |