- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $2,951.21
| Professional | | $1,995.26 | $2,570.40 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $1,995.26 / $5,888.44
| Professional | | $239.88 | $1,995.26 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,754.23 / $6,760.83
| Facility | | $2,570.40 | $2,754.23 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $15,135.61
| Professional | | $1,288.25 | $1,819.70 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $3,467.37
| Professional | | $1,288.25 | $1,819.70 | $3,467.37 |