- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,677.35 / $4,677.35
| Professional | | $2,454.71 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,570.88 / $4,786.30
| Professional | | $4,168.69 | $4,570.88 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $7,079.46
| Professional | | $3,630.78 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $5,248.07
| Facility | | $1,122.02 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,388.44
| Professional | | $1,412.54 | $1,862.09 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $512.86 / $3,311.31
| Facility | | $251.19 | $512.86 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,388.44
| Professional | | $1,412.54 | $1,862.09 | $3,388.44 |