- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,754.23 / $3,388.44
| Professional | | $2,570.40 | $2,754.23 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $2,290.87 / $3,981.07
| Professional | | $269.15 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,318.26 / $2,089.30
| Professional | | $281.84 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $3,715.35
| Professional | | $2,238.72 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $338.84 / $4,466.84
| Professional | | $288.40 | $338.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $331.13 / $2,818.38
| Facility | | $190.55 | $331.13 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $1,737.80 / $3,981.07
| Professional | | $257.04 | $1,737.80 | $3,981.07 |