- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.04 / $2,077.36 / $9,175.45
| Professional | | $1,709.04 | $2,077.36 | $9,175.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.00 / $1,978.66 / $2,259.61
| Professional | | $1,390.00 | $1,978.66 | $2,259.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.35 / $3,076.35 / $3,076.35
| Facility | | $3,076.35 | $3,076.35 | $3,076.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.16 / $2,312.08 / $4,517.14
| Professional | | $1,577.16 | $2,312.08 | $4,517.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.98 / $2,314.23 / $4,032.10
| Professional | | $1,793.98 | $2,314.23 | $4,032.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.63 / $2,005.29 / $3,467.09
| Professional | | $1,473.63 | $2,005.29 | $3,467.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.41 / $2,063.08 / $2,547.32
| Professional | | $1,424.41 | $2,063.08 | $2,547.32 |