- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.44 / $2,104.13 / $11,142.30
| Professional | | $1,856.44 | $2,104.13 | $11,142.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,296.77 / $3,296.77 / $3,296.77
| Professional | | $3,296.77 | $3,296.77 | $3,296.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,296.77 / $3,296.77 / $3,296.77
| Facility | | $3,296.77 | $3,296.77 | $3,296.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,045.51 / $3,296.77 / $6,136.98
| Professional | | $2,045.51 | $3,296.77 | $6,136.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,801.16 / $2,905.89 / $4,049.27
| Facility | | $1,801.16 | $2,905.89 | $4,049.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.83 / $3,344.66 / $5,573.40
| Professional | | $2,165.83 | $3,344.66 | $5,573.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.24 / $3,607.53 / $5,780.31
| Professional | | $2,945.24 | $3,607.53 | $5,780.31 |