- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.90 / $1,403.78 / $1,555.54
| Professional | | $1,327.90 | $1,403.78 | $1,555.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $3,889.91 / $4,391.56
| Facility | | $0.02 | $3,889.91 | $4,391.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.53 / $2,513.53 / $2,513.53
| Professional | | $2,513.53 | $2,513.53 | $2,513.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,609.28 / $5,609.28 / $5,609.28
| Facility | | $5,609.28 | $5,609.28 | $5,609.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $1,138.20 / $2,736.04
| Professional | | $796.74 | $1,138.20 | $2,736.04 |