- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,752.55 / $3,047.37 / $4,545.53
| Professional | | $2,752.55 | $3,047.37 | $4,545.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.77 / $1,166.77 / $3,105.28
| Professional | | $1,166.77 | $1,166.77 | $3,105.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.37 / $773.37 / $773.37
| Facility | | $773.37 | $773.37 | $773.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.21 / $456.21 / $456.21
| Professional | | $456.21 | $456.21 | $456.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,432.58 / $2,673.00 / $3,305.35
| Facility | | $2,432.58 | $2,673.00 | $3,305.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.88 / $2,673.00 / $2,673.00
| Professional | | $343.88 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.31 / $1,958.79 / $4,002.37
| Professional | | $1,119.31 | $1,958.79 | $4,002.37 |