- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.54 / $2,785.48 / $3,157.12
| Professional | | $2,493.54 | $2,785.48 | $3,157.12 |
- 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
- $2,446.40 / $2,446.40 / $3,210.83
| Facility | | $2,446.40 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.44 / $2,446.40 / $4,372.50
| Professional | | $2,079.44 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.51 / $2,739.49 / $4,847.72
| Facility | | $366.51 | $2,739.49 | $4,847.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.76 / $1,798.88 / $3,997.50
| Professional | | $1,435.76 | $1,798.88 | $3,997.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.76 / $1,782.92 / $3,997.50
| Professional | | $1,435.76 | $1,782.92 | $3,997.50 |