- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.11 / $2,748.12 / $3,435.15
| Professional | | $1,754.11 | $2,748.12 | $3,435.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.17 / $5,281.80 / $5,281.80
| Professional | | $528.17 | $5,281.80 | $5,281.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.12 / $3,248.38 / $7,654.69
| Professional | | $2,761.12 | $3,248.38 | $7,654.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.11 / $2,748.12 / $3,435.15
| Professional | | $1,754.11 | $2,748.12 | $3,435.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.13 / $3,248.38 / $7,654.69
| Professional | | $453.13 | $3,248.38 | $7,654.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,780.86 / $4,992.30 / $4,992.30
| Professional | | $3,780.86 | $4,992.30 | $4,992.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.65 / $2,827.76 / $5,533.04
| Professional | | $2,004.65 | $2,827.76 | $5,533.04 |