- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $5,011.87
| Facility | | $1,096.48 | $1,995.26 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $2,630.27
| Professional | | $1,737.80 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,089.30 / $3,981.07
| Facility | | $602.56 | $2,089.30 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,238.72 / $5,495.41
| Facility | | $741.31 | $2,238.72 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |