- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,073.80
| Professional | | $3,162.28 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $2,290.87 / $3,311.31
| Professional | | $269.15 | $2,290.87 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,011.87 / $5,011.87
| Professional | | $4,786.30 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $3,801.89
| Professional | | $398.11 | $398.11 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $245.47 / $2,818.38
| Facility | | $239.88 | $245.47 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $3,090.30
| Professional | | $1,348.96 | $2,290.87 | $3,090.30 |