- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.48 / $1,646.10 / $2,057.63
| Professional | | $1,043.48 | $1,646.10 | $2,057.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.58 / $3,145.80 / $3,145.80
| Professional | | $314.58 | $3,145.80 | $3,145.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $1,850.09
| Facility | | $1,850.09 | $1,850.09 | $1,850.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.58 / $1,572.58 / $4,560.93
| Professional | | $1,572.58 | $1,572.58 | $4,560.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.48 / $1,646.10 / $2,057.63
| Professional | | $1,043.48 | $1,646.10 | $2,057.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $1,850.09
| Facility | | $1,850.09 | $1,850.09 | $1,850.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.58 / $1,850.09 / $4,560.93
| Professional | | $1,572.58 | $1,850.09 | $4,560.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.21 / $2,990.40 / $2,990.40
| Professional | | $2,249.21 | $2,990.40 | $2,990.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.14 / $1,887.48 / $3,767.63
| Professional | | $1,555.14 | $1,887.48 | $3,767.63 |