- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,238.72
| Professional | | $1,479.11 | $1,737.80 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $2,137.96
| Professional | | $1,548.82 | $1,905.46 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $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
- $147.91 / $234.42 / $2,137.96
| Facility | | $147.91 | $234.42 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,148.15 / $1,995.26
| Professional | | $263.03 | $1,148.15 | $1,995.26 |