- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,454.71 / $3,715.35
| Professional | | $1,318.26 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $3,162.28
| Professional | | $1,995.26 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $2,884.03
| Facility | | $575.44 | $602.56 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,884.03 / $5,754.40
| Professional | | $776.25 | $2,884.03 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $2,570.40
| Professional | | $1,348.96 | $1,778.28 | $2,570.40 |
- 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
- $1,445.44 / $2,187.76 / $3,890.45
| Professional | | $1,445.44 | $2,187.76 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |