- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.32 / $3,110.82 / $3,888.53
| Professional | | $1,979.32 | $3,110.82 | $3,888.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.73 / $4,521.04 / $5,967.30
| Professional | | $596.73 | $4,521.04 | $5,967.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $4,198.50
| Facility | | $1,642.21 | $1,642.21 | $4,198.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.88 / $1,642.21 / $8,648.44
| Professional | | $1,395.88 | $1,642.21 | $8,648.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,733.14 / $3,733.14 / $3,733.14
| Professional | | $3,733.14 | $3,733.14 | $3,733.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.32 / $3,196.11 / $3,954.86
| Professional | | $1,979.32 | $3,196.11 | $3,954.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $4,198.50
| Facility | | $1,642.21 | $1,642.21 | $4,198.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $1,642.21 / $8,648.44
| Professional | | $513.41 | $1,642.21 | $8,648.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,266.47 / $5,651.30 / $5,651.30
| Professional | | $4,266.47 | $5,651.30 | $5,651.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.12 / $3,197.61 / $5,740.53
| Professional | | $2,262.12 | $3,197.61 | $5,740.53 |