- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,311.31
| Professional | | $2,630.27 | $2,630.27 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,290.87 / $5,011.87
| Facility | | $54.95 | $2,290.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,884.03 / $14,791.08
| Professional | | $2,137.96 | $2,884.03 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $2,754.23
| Professional | | $2,290.87 | $2,691.53 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,398.83
| Professional | | $2,344.23 | $2,344.23 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $1,819.70
| Professional | | $1,071.52 | $1,288.25 | $1,819.70 |