- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $2,754.23
| Professional | | $1,479.11 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,754.23
| Professional | | $1,905.46 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,398.83
| Facility | | $2,041.74 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,398.83 / $3,981.07
| Professional | | $251.19 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,238.72 / $2,818.38
| Professional | | $2,187.76 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $269.15 / $1,778.28
| Facility | | $186.21 | $269.15 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,905.46
| Professional | | $1,148.15 | $1,230.27 | $1,905.46 |