- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $2,691.53
| Professional | | $1,513.56 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $123.03 / $186.21
| Facility | | $112.20 | $123.03 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $6,606.93
| Professional | | $2,398.83 | $3,019.95 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $2,398.83 / $3,981.07
| Professional | | $257.04 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $2,137.96 / $3,388.44
| Facility | | $331.13 | $2,137.96 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,818.38
| Professional | | $1,202.26 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $338.84 / $2,238.72
| Facility | | $144.54 | $338.84 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,818.38
| Professional | | $1,202.26 | $1,445.44 | $2,818.38 |