- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,467.37
| Professional | | $2,398.83 | $2,398.83 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,137.96 / $2,398.83
| Professional | | $251.19 | $2,137.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,981.07 / $3,981.07
| Professional | | $3,801.89 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $2,454.71
| Professional | | $257.04 | $257.04 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $234.42 / $2,137.96
| Facility | | $199.53 | $234.42 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,905.46 / $2,570.40
| Professional | | $1,096.48 | $1,905.46 | $2,570.40 |