- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $3,548.13
| Professional | | $1,202.26 | $1,479.11 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $3,981.07
| Professional | | $1,230.27 | $1,819.70 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $2,570.40
| Facility | | $2,238.72 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $2,570.40
| Professional | | $2,238.72 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,235.94
| Facility | | $1,258.93 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,137.96 / $3,467.37
| Professional | | $79.43 | $2,137.96 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,187.76 / $2,754.23
| Professional | | $1,737.80 | $2,187.76 | $2,754.23 |