- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.32 / $1,883.09 / $1,883.09
| Professional | | $1,772.32 | $1,883.09 | $1,883.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,990.79 / $12,461.63 / $59,815.80
| Facility | | $2,990.79 | $12,461.63 | $59,815.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,658.48 / $2,990.79 / $119,998.80
| Professional | | $2,658.48 | $2,990.79 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.48 / $2,658.48 / $2,658.48
| Facility | | $2,658.48 | $2,658.48 | $2,658.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,678.23 / $10,678.23 / $10,678.23
| Professional | | $10,678.23 | $10,678.23 | $10,678.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,107.70 / $3,212.33
| Professional | | $930.47 | $1,107.70 | $3,212.33 |