- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,162.28 / $4,570.88
| Professional | | $2,884.03 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $2,630.27
| Professional | | $2,089.30 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,388.44
| Facility | | $2,691.53 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,691.53 / $3,388.44
| Professional | | $346.74 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,801.89 / $3,801.89
| Professional | | $1,548.82 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,570.88 / $4,677.35
| Professional | | $2,884.03 | $4,570.88 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $331.13 / $3,235.94
| Facility | | $323.59 | $331.13 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,754.23 / $4,365.16
| Professional | | $1,122.02 | $2,754.23 | $4,365.16 |