- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.07 / $1,764.61 / $1,764.61
| Professional | | $794.07 | $1,764.61 | $1,764.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.97 / $1,335.63 / $1,335.63
| Facility | | $1,263.97 | $1,335.63 | $1,335.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $975.01 / $1,375.70
| Professional | | $975.01 | $975.01 | $1,375.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.04 / $1,419.53 / $2,015.23
| Facility | | $594.04 | $1,419.53 | $2,015.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.71 / $1,914.47 / $2,015.23
| Professional | | $1,813.71 | $1,914.47 | $2,015.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,505.52 / $1,813.71
| Professional | | $30.00 | $1,505.52 | $1,813.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,764.61 / $1,968.00 / $2,952.00
| Facility | | $1,764.61 | $1,968.00 | $2,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.66 / $1,461.12 / $2,115.98
| Professional | | $1,410.66 | $1,461.12 | $2,115.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.78 / $920.18 / $1,459.40
| Professional | | $850.78 | $920.18 | $1,459.40 |