- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.52 / $2,469.28 / $2,469.28
| Professional | | $1,873.52 | $2,469.28 | $2,469.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $3,023.21
| Facility | | $2,217.64 | $2,217.64 | $3,023.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,059.25 / $3,089.84 / $3,824.06
| Professional | | $3,059.25 | $3,089.84 | $3,824.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,265.81 / $5,133.43 / $12,404.85
| Facility | | $2,265.81 | $5,133.43 | $12,404.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.21 / $2,024.42 / $2,388.69
| Professional | | $1,012.21 | $2,024.42 | $2,388.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.04 / $302.32 / $302.32
| Facility | | $300.04 | $302.32 | $302.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.04 / $570.30 / $3,127.11
| Professional | | $300.04 | $570.30 | $3,127.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.21 / $1,544.75 / $2,388.69
| Professional | | $1,012.21 | $1,544.75 | $2,388.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.53 / $2,473.53 / $2,473.53
| Professional | | $2,473.53 | $2,473.53 | $2,473.53 |