- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.54 / $2,941.62 / $4,845.47
| Professional | | $2,389.54 | $2,941.62 | $4,845.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.81 / $490.27 / $490.27
| Professional | | $464.81 | $490.27 | $490.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,650.37
| Facility | | $3,626.76 | $3,626.76 | $3,650.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,626.76 / $5,715.00
| Professional | | $387.52 | $3,626.76 | $5,715.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.67 / $3,088.70 / $5,237.12
| Facility | | $388.67 | $3,088.70 | $5,237.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $2,422.69 / $4,551.50
| Professional | | $1,494.94 | $2,422.69 | $4,551.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $2,478.96 / $4,551.50
| Professional | | $1,494.94 | $2,478.96 | $4,551.50 |