- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $4,168.69
| Professional | | $2,884.03 | $2,884.03 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $2,691.53 / $2,884.03
| Professional | | $288.40 | $2,691.53 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,677.35 / $4,677.35
| Professional | | $4,466.84 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $3,311.31
| Professional | | $354.81 | $354.81 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $257.04 / $2,691.53
| Facility | | $239.88 | $257.04 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,290.87 / $3,090.30
| Professional | | $1,318.26 | $2,290.87 | $3,090.30 |