- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.42 / $2,818.16 / $3,175.81
| Professional | | $2,226.42 | $2,818.16 | $3,175.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.08 / $355.40 / $355.40
| Professional | | $302.08 | $355.40 | $355.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.10 / $2,290.69 / $3,236.31
| Professional | | $1,947.10 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.97 / $204.97 / $2,383.14
| Facility | | $204.97 | $204.97 | $2,383.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.60 / $2,076.40 / $3,012.60
| Professional | | $1,385.60 | $2,076.40 | $3,012.60 |