- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $5,128.61
| Professional | | $3,715.35 | $3,715.35 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,548.13 / $3,630.78
| Professional | | $389.05 | $3,548.13 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,570.88 / $5,754.40
| Professional | | $4,365.16 | $4,570.88 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $4,073.80
| Professional | | $436.52 | $436.52 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $371.54 / $3,311.31
| Facility | | $323.59 | $371.54 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,090.30 / $4,168.69
| Professional | | $1,737.80 | $3,090.30 | $4,168.69 |