- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.62 / $3,215.34 / $3,215.34
| Professional | | $2,306.62 | $3,215.34 | $3,215.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.59 / $922.59 / $922.59
| Professional | | $922.59 | $922.59 | $922.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,889.03 / $7,909.24 / $8,621.99
| Facility | | $3,889.03 | $7,909.24 | $8,621.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.21 / $2,290.73 / $3,961.91
| Professional | | $1,203.21 | $2,290.73 | $3,961.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.64 / $1,163.29 / $4,261.12
| Professional | | $85.64 | $1,163.29 | $4,261.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.13 / $891.76 / $1,407.49
| Professional | | $743.13 | $891.76 | $1,407.49 |