- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,042.28 / $2,190.44 / $10,537.60
| Professional | | $2,042.28 | $2,190.44 | $10,537.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,380.96 / $2,380.96 / $2,975.00
| Professional | | $2,380.96 | $2,380.96 | $2,975.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.46 / $2,808.12 / $5,546.30
| Professional | | $1,898.46 | $2,808.12 | $5,546.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.73 / $3,034.71 / $4,784.47
| Professional | | $2,281.73 | $3,034.71 | $4,784.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.00 / $661.00 / $661.00
| Facility | | $661.00 | $661.00 | $661.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.83 / $2,490.15 / $4,748.24
| Professional | | $1,719.83 | $2,490.15 | $4,748.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.23 / $2,624.00 / $3,142.86
| Professional | | $1,885.23 | $2,624.00 | $3,142.86 |