- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.30 / $1,486.04 / $1,486.04
| Professional | | $1,105.30 | $1,486.04 | $1,486.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $902.06 / $902.06 / $1,561.58
| Facility | | $902.06 | $902.06 | $1,561.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.75 / $1,897.54 / $2,348.44
| Professional | | $1,878.75 | $1,897.54 | $2,348.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.97 / $3,028.52 / $8,508.41
| Facility | | $1,285.97 | $3,028.52 | $8,508.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.20 / $1,292.40 / $1,523.54
| Professional | | $646.20 | $1,292.40 | $1,523.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.00 / $178.38 / $178.38
| Facility | | $177.00 | $178.38 | $178.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.00 / $336.31 / $1,844.72
| Professional | | $177.00 | $336.31 | $1,844.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.55 / $952.21 / $1,523.54
| Professional | | $629.55 | $952.21 | $1,523.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.44 / $1,459.44 / $1,459.44
| Professional | | $1,459.44 | $1,459.44 | $1,459.44 |