- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.86 / $1,626.42 / $2,033.03
| Professional | | $1,026.86 | $1,626.42 | $2,033.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,357.19 / $3,095.70 / $3,095.70
| Professional | | $2,357.19 | $3,095.70 | $3,095.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.75 / $1,406.76 / $4,485.93
| Professional | | $1,195.75 | $1,406.76 | $4,485.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.98 / $2,166.98 / $2,321.78
| Professional | | $2,166.98 | $2,166.98 | $2,321.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.86 / $1,626.42 / $2,033.03
| Professional | | $1,026.86 | $1,626.42 | $2,033.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.74 / $1,406.76 / $4,485.93
| Professional | | $229.74 | $1,406.76 | $4,485.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.37 / $2,946.50 / $2,946.50
| Professional | | $2,213.37 | $2,946.50 | $2,946.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.49 / $1,405.84 / $2,538.55
| Professional | | $1,011.49 | $1,405.84 | $2,538.55 |