- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,754.23 / $3,467.37
| Professional | | $1,348.96 | $2,754.23 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $33,884.42 / $33,884.42
| Facility | | $6,025.60 | $33,884.42 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $954.99 / $1,513.56
| Facility | | $724.44 | $954.99 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $1,318.26 / $1,659.59
| Professional | | $5.01 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $977.24 / $1,513.56
| Facility | | $724.44 | $977.24 | $1,513.56 |