- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.05 / $3,027.18 / $4,966.43
| Professional | | $1,796.05 | $3,027.18 | $4,966.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.34 / $504.53 / $504.53
| Professional | | $349.34 | $504.53 | $504.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $5,636.78
| Facility | | $3,282.89 | $3,282.89 | $5,636.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $6,731.25
| Professional | | $456.28 | $3,282.89 | $6,731.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.41 / $4,085.91 / $30,467.00
| Facility | | $1,862.41 | $4,085.91 | $30,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.53 / $3,067.50 / $4,519.46
| Professional | | $1,955.53 | $3,067.50 | $4,519.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,383.30 / $3,067.50 / $4,506.60
| Professional | | $2,383.30 | $3,067.50 | $4,506.60 |