- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.80 / $1,973.14 / $3,282.84
| Professional | | $1,926.80 | $1,973.14 | $3,282.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,211.33 / $3,211.33 / $3,211.33
| Professional | | $3,211.33 | $3,211.33 | $3,211.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.11 / $4,060.88 / $7,341.91
| Facility | | $1,124.11 | $4,060.88 | $7,341.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,810.30 / $3,747.06 / $5,058.54
| Professional | | $2,810.30 | $3,747.06 | $5,058.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $2,448.80
| Facility | | $2,448.80 | $2,448.80 | $2,448.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $1,787.62 / $5,085.75
| Professional | | $1,787.62 | $1,787.62 | $5,085.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.19 / $2,860.96 / $20,504.11
| Facility | | $1,262.19 | $2,860.96 | $20,504.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.07 / $1,955.12 / $3,012.78
| Professional | | $1,767.07 | $1,955.12 | $3,012.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.07 / $1,955.12 / $2,945.12
| Professional | | $1,767.07 | $1,955.12 | $2,945.12 |