- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.42 / $2,264.69 / $3,570.00
| Professional | | $2,226.42 | $2,264.69 | $3,570.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.45 / $377.45 / $433.07
| Professional | | $377.45 | $377.45 | $433.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.08 / $2,290.69 / $3,993.75
| Professional | | $268.08 | $2,290.69 | $3,993.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.61 / $2,736.08 / $4,879.47
| Facility | | $273.61 | $2,736.08 | $4,879.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.44 / $2,184.84 / $3,948.50
| Professional | | $1,154.44 | $2,184.84 | $3,948.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.97 / $329.01 / $2,476.16
| Facility | | $204.97 | $329.01 | $2,476.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.44 / $2,166.64 / $3,948.50
| Professional | | $1,154.44 | $2,166.64 | $3,948.50 |