- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $6,025.60
| Professional | | $2,041.74 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,162.28
| Professional | | $2,238.72 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $645.65
| Facility | | $512.86 | $512.86 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $5,248.07
| Professional | | $1,995.26 | $2,884.03 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $4,265.80
| Professional | | $2,398.83 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $371.54 / $2,290.87
| Facility | | $158.49 | $371.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $4,897.79
| Professional | | $1,819.70 | $2,691.53 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $3,715.35
| Professional | | $1,995.26 | $2,884.03 | $3,715.35 |