- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.84 / $2,373.42 / $4,497.09
| Professional | | $2,211.84 | $2,373.42 | $4,497.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.57 / $395.57 / $430.24
| Professional | | $395.57 | $395.57 | $430.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,937.79
| Facility | | $2,446.40 | $2,446.40 | $2,937.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $4,372.50
| Professional | | $286.94 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.55 / $2,718.32 / $4,847.72
| Facility | | $272.55 | $2,718.32 | $4,847.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.47 / $2,170.62 / $3,997.50
| Professional | | $1,196.47 | $2,170.62 | $3,997.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.47 / $2,127.44 / $3,997.50
| Professional | | $1,196.47 | $2,127.44 | $3,997.50 |