- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.90 / $1,357.12 / $1,700.16
| Professional | | $784.90 | $1,357.12 | $1,700.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.27 / $1,966.91 / $2,583.10
| Professional | | $258.27 | $1,966.91 | $2,583.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $3,743.44
| Professional | | $1,241.43 | $1,460.50 | $3,743.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.44 / $2,376.44 / $2,583.10
| Professional | | $2,376.44 | $2,376.44 | $2,583.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.63 / $1,808.17 / $1,937.33
| Professional | | $1,641.63 | $1,808.17 | $1,937.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.36 / $1,387.41 / $2,040.00
| Professional | | $728.36 | $1,387.41 | $2,040.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $3,743.44
| Professional | | $1,241.43 | $1,460.50 | $3,743.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.79 / $2,458.64 / $2,458.64
| Professional | | $1,846.79 | $2,458.64 | $2,458.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.60 / $1,288.68 / $2,147.80
| Professional | | $906.60 | $1,288.68 | $2,147.80 |