- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $3,467.37
| Professional | | $2,187.76 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $3,467.37
| Professional | | $2,344.23 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,630.78 / $5,754.40
| Professional | | $389.05 | $3,630.78 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,365.16
| Professional | | $3,388.44 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $371.54 / $3,311.31
| Facility | | $251.19 | $371.54 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,862.09 / $3,630.78
| Professional | | $407.38 | $1,862.09 | $3,630.78 |