- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,630.78 / $6,025.60
| Professional | | $1,445.44 | $3,630.78 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $1,230.27 / $2,344.23
| Professional | | $7.08 | $1,230.27 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $2,041.74 / $4,168.69
| Facility | | $309.03 | $2,041.74 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,905.46
| Professional | | $794.33 | $1,096.48 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $50,118.72
| Facility | | $13,803.84 | $13,803.84 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |