- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $4,466.84
| Professional | | $2,041.74 | $2,454.71 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $3,388.44
| Professional | | $2,137.96 | $2,398.83 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $3,801.89
| Facility | | $575.44 | $602.56 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,677.35
| Professional | | $1,862.09 | $2,630.27 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $3,388.44
| Professional | | $1,862.09 | $2,454.71 | $3,388.44 |
- 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
- $1,862.09 / $2,570.40 / $4,466.84
| Professional | | $1,862.09 | $2,570.40 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $3,162.28
| Professional | | $1,905.46 | $2,754.23 | $3,162.28 |