- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.61 / $1,607.73 / $2,184.16
| Professional | | $1,264.61 | $1,607.73 | $2,184.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.46 / $3,097.56 / $5,600.26
| Facility | | $857.46 | $3,097.56 | $5,600.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.64 / $2,858.19 / $3,894.29
| Professional | | $2,143.64 | $2,858.19 | $3,894.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,667.14 / $3,804.00
| Professional | | $1,667.14 | $1,667.14 | $3,804.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.01 / $1,789.96 / $14,087.74
| Facility | | $863.01 | $1,789.96 | $14,087.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.22 / $1,336.80 / $2,059.96
| Professional | | $1,208.22 | $1,336.80 | $2,059.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.22 / $1,336.80 / $2,013.70
| Professional | | $1,208.22 | $1,336.80 | $2,013.70 |