- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.09 / $1,127.81 / $2,005.85
| Professional | | $1,074.09 | $1,127.81 | $2,005.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $644.46 / $2,328.13 / $4,209.16
| Facility | | $644.46 | $2,328.13 | $4,209.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.16 / $2,148.21 / $2,926.93
| Professional | | $1,611.16 | $2,148.21 | $2,926.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $1,544.16
| Facility | | $1,544.16 | $1,544.16 | $1,544.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,127.24 / $2,767.50
| Professional | | $1,127.24 | $1,127.24 | $2,767.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.64 / $1,794.22 / $10,889.05
| Facility | | $648.64 | $1,794.22 | $10,889.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.19 / $1,004.74 / $1,513.50
| Professional | | $907.19 | $1,004.74 | $1,513.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.19 / $1,004.74 / $1,513.50
| Professional | | $907.19 | $1,004.74 | $1,513.50 |