- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $7,585.78
| Professional | | $3,467.37 | $4,073.80 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,981.07 / $5,754.40
| Professional | | $3,630.78 | $3,981.07 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $6,456.54
| Facility | | $575.44 | $602.56 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,265.80 / $7,762.47
| Professional | | $2,041.74 | $4,265.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,073.80 / $5,623.41
| Professional | | $3,019.95 | $4,073.80 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,230.27
| Facility | | $302.00 | $416.87 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,168.69 / $7,585.78
| Professional | | $2,691.53 | $4,168.69 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,570.88 / $5,248.07
| Professional | | $3,090.30 | $4,570.88 | $5,248.07 |