- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.08 / $1,960.27 / $1,960.27
| Professional | | $1,058.08 | $1,960.27 | $1,960.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $1,684.23
| Facility | | $1,544.16 | $1,544.16 | $1,684.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,544.16 / $1,590.48
| Professional | | $1,127.24 | $1,544.16 | $1,590.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.64 / $1,680.70 / $2,238.67
| Facility | | $648.64 | $1,680.70 | $2,238.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.81 / $2,126.75 / $2,238.67
| Professional | | $2,014.81 | $2,126.75 | $2,238.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,652.14 / $1,967.59
| Professional | | $30.00 | $1,652.14 | $1,967.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.27 / $2,186.21 / $3,279.32
| Facility | | $1,960.27 | $2,186.21 | $3,279.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.08 / $1,567.08 / $2,350.61
| Professional | | $1,567.08 | $1,567.08 | $2,350.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.29 / $1,004.74 / $1,593.50
| Professional | | $912.29 | $1,004.74 | $1,593.50 |