- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.81 / $2,781.04 / $3,521.66
| Professional | | $1,368.81 | $2,781.04 | $3,521.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,800.00 / $13,851.75
| Facility | | $55.00 | $2,800.00 | $13,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,701.47 / $3,783.07 / $3,783.07
| Professional | | $3,701.47 | $3,783.07 | $3,783.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,115.88 / $6,674.61 / $15,806.70
| Facility | | $3,115.88 | $6,674.61 | $15,806.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.63 / $1,176.26 / $1,358.10
| Professional | | $914.63 | $1,176.26 | $1,358.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $950.10 / $1,881.90
| Professional | | $7.00 | $950.10 | $1,881.90 |