- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,128.61 / $5,128.61
| Professional | | $3,235.94 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $2,344.23
| Professional | | $1,905.46 | $2,238.72 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $2,290.87 / $3,311.31
| Facility | | $478.63 | $2,290.87 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $5,128.61
| Professional | | $60.26 | $60.26 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $478.63 / $4,786.30
| Facility | | $346.74 | $478.63 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $741.31 / $4,786.30
| Professional | | $346.74 | $741.31 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $3,388.44
| Facility | | $2,290.87 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,905.46 / $2,344.23
| Professional | | $60.26 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $245.47 / $2,511.89
| Facility | | $194.98 | $245.47 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,090.30 / $5,623.41
| Professional | | $1,621.81 | $3,090.30 | $5,623.41 |