- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,344.23
| Professional | | $1,412.54 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $2,398.83
| Facility | | $2,344.23 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,398.83 / $3,981.07
| Professional | | $251.19 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $1,737.80 / $2,570.40
| Facility | | $218.78 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,380.38 / $2,511.89
| Professional | | $758.58 | $1,380.38 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $338.84 / $2,137.96
| Facility | | $162.18 | $338.84 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,412.54 / $2,511.89
| Professional | | $954.99 | $1,412.54 | $2,511.89 |