- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.04 / $3,683.78 / $4,745.60
| Professional | | $2,453.04 | $3,683.78 | $4,745.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.15 / $491.17 / $491.17
| Professional | | $477.15 | $491.17 | $491.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $3,628.77
| Facility | | $2,673.00 | $2,673.00 | $3,628.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.53 / $2,673.00 / $5,756.25
| Professional | | $378.53 | $2,673.00 | $5,756.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.62 / $3,094.37 / $5,376.08
| Facility | | $287.62 | $3,094.37 | $5,376.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.04 / $2,521.87 / $4,433.20
| Professional | | $1,486.04 | $2,521.87 | $4,433.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.04 / $2,387.14 / $4,433.20
| Professional | | $1,486.04 | $2,387.14 | $4,433.20 |