- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.54 / $2,938.86 / $4,845.47
| Professional | | $2,389.54 | $2,938.86 | $4,845.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.81 / $489.81 / $489.81
| Professional | | $464.81 | $489.81 | $489.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,646.95
| Facility | | $3,621.85 | $3,621.85 | $3,646.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $5,707.50
| Professional | | $386.96 | $3,621.85 | $5,707.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.67 / $3,085.80 / $5,237.12
| Facility | | $388.67 | $3,085.80 | $5,237.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $2,421.39 / $4,551.50
| Professional | | $1,494.94 | $2,421.39 | $4,551.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $2,344.98 / $4,551.50
| Professional | | $1,494.94 | $2,344.98 | $4,551.50 |