- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $2,238.72 / $6,760.83
| Professional | | $812.83 | $2,238.72 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $912.01 / $2,454.71
| Facility | | $407.38 | $912.01 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $478.63 / $3,548.13
| Professional | | $3.98 | $478.63 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $19,498.45 / $19,498.45
| Facility | | $4,677.35 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,309.57 / $6,309.57
| Professional | | $6,165.95 | $6,309.57 | $6,309.57 |