- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.86 / $1,658.28 / $7,657.53
| Professional | | $1,237.86 | $1,658.28 | $7,657.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Facility | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.13 / $2,217.64 / $2,217.64
| Professional | | $2,074.13 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.12 / $395.85 / $3,238.05
| Professional | | $211.12 | $395.85 | $3,238.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.67 / $1,613.67 / $2,078.69
| Facility | | $1,613.67 | $1,613.67 | $2,078.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.13 / $2,217.64 / $2,217.64
| Professional | | $2,074.13 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.08 / $1,324.07 / $1,825.47
| Professional | | $1,027.08 | $1,324.07 | $1,825.47 |