- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.83 / $1,146.83 / $1,433.54
| Professional | | $1,146.83 | $1,146.83 | $1,433.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,537.60 / $15,537.60 / $15,537.60
| Facility | | $15,537.60 | $15,537.60 | $15,537.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.00 / $2,962.34 / $2,962.34
| Professional | | $797.00 | $2,962.34 | $2,962.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.01 / $736.14 / $865.63
| Facility | | $568.01 | $736.14 | $865.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.01 / $935.91 / $1,193.66
| Professional | | $568.01 | $935.91 | $1,193.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $567.29 / $1,066.40
| Professional | | $5.00 | $567.29 | $1,066.40 |