- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $7,762.47
| Professional | | $2,818.38 | $2,818.38 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,570.88 / $9,332.54
| Facility | | $3,019.95 | $4,570.88 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,570.88 / $9,332.54
| Professional | | $3,019.95 | $4,570.88 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $6,606.93
| Facility | | $2,691.53 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $4,365.16
| Professional | | $79.43 | $79.43 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $5,248.07
| Professional | | $1,288.25 | $1,288.25 | $5,248.07 |