- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.32 / $2,210.32 / $2,210.32
| Professional | | $2,210.32 | $2,210.32 | $2,210.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.90 / $2,476.36 / $2,606.69
| Professional | | $2,293.90 | $2,476.36 | $2,606.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $2,207.92
| Facility | | $1,639.62 | $1,639.62 | $2,207.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.62 / $2,159.78 / $3,471.98
| Professional | | $1,639.62 | $2,159.78 | $3,471.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.89 / $2,210.32 / $11,977.62
| Facility | | $226.89 | $2,210.32 | $11,977.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.04 / $1,021.17 / $1,778.71
| Professional | | $642.04 | $1,021.17 | $1,778.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.76 / $293.62 / $561.11
| Facility | | $292.76 | $293.62 | $561.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.62 / $366.91 / $694.02
| Professional | | $293.62 | $366.91 | $694.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.04 / $1,021.17 / $1,776.22
| Professional | | $642.04 | $1,021.17 | $1,776.22 |