- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.87 / $3,110.82 / $3,954.86
| Professional | | $1,827.87 | $3,110.82 | $3,954.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.54 / $518.47 / $518.47
| Professional | | $355.54 | $518.47 | $518.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $5,792.58
| Facility | | $1,642.21 | $1,642.21 | $5,792.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $6,918.75
| Professional | | $470.42 | $1,642.21 | $6,918.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.41 / $4,082.96 / $31,412.20
| Facility | | $1,895.41 | $4,082.96 | $31,412.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.18 / $3,121.85 / $4,615.85
| Professional | | $1,990.18 | $3,121.85 | $4,615.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.10 / $3,121.85 / $4,599.54
| Professional | | $2,449.10 | $3,121.85 | $4,599.54 |