- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.01 / $2,136.26 / $2,136.26
| Professional | | $1,709.01 | $2,136.26 | $2,136.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.55 / $203.55 / $268.68
| Professional | | $203.55 | $203.55 | $268.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,638.91 / $3,267.23 / $3,518.55
| Facility | | $2,638.91 | $3,267.23 | $3,518.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.25 / $3,015.90 / $3,769.88
| Professional | | $2,513.25 | $3,015.90 | $3,769.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.32 / $3,061.40 / $14,447.07
| Professional | | $1.32 | $3,061.40 | $14,447.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,507.95 / $2,513.25
| Professional | | $1,055.57 | $1,507.95 | $2,513.25 |