- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,737.80 / $3,467.37
| Professional | | $1,659.59 | $1,737.80 | $3,467.37 |
- 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
- $281.84 / $2,041.74 / $2,398.83
| Professional | | $281.84 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $309.03 / $3,090.30
| Facility | | $263.03 | $309.03 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $363.08 / $3,090.30
| Professional | | $263.03 | $363.08 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $380.19 / $380.19
| Professional | | $316.23 | $380.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.05 / $234.42 / $2,137.96
| Facility | | $19.05 | $234.42 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $2,187.76
| Professional | | $1,148.15 | $1,230.27 | $2,187.76 |