- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.26 / $1,787.42 / $1,787.42
| Professional | | $1,160.26 | $1,787.42 | $1,787.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,020.64 / $1,333.66
| Facility | | $1,020.64 | $1,020.64 | $1,333.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $1,051.26
| Professional | | $745.07 | $1,020.64 | $1,051.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.63 / $1,497.80 / $2,126.34
| Facility | | $513.63 | $1,497.80 | $2,126.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.71 / $2,020.02 / $2,126.34
| Professional | | $1,913.71 | $2,020.02 | $2,126.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,569.24 / $1,868.85
| Professional | | $30.00 | $1,569.24 | $1,868.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.90 / $2,076.50 / $3,114.75
| Facility | | $1,861.90 | $2,076.50 | $3,114.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.44 / $1,488.44 / $2,232.66
| Professional | | $1,488.44 | $1,488.44 | $2,232.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.60 / $795.61 / $1,420.76
| Professional | | $735.60 | $795.61 | $1,420.76 |