- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,372.03 / $2,785.48 / $3,002.96
| Professional | | $2,372.03 | $2,785.48 | $3,002.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.10 / $124.10 / $155.13
| Facility | | $124.10 | $124.10 | $155.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.06 / $3,226.75 / $5,364.48
| Professional | | $2,420.06 | $3,226.75 | $5,364.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $5,643.75
| Professional | | $286.64 | $2,671.66 | $5,643.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.63 / $2,391.12 / $3,710.38
| Facility | | $351.63 | $2,391.12 | $3,710.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.32 / $1,575.56 / $3,449.10
| Professional | | $1,361.32 | $1,575.56 | $3,449.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.32 / $1,552.10 / $3,449.10
| Professional | | $1,361.32 | $1,552.10 | $3,449.10 |