- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,019.95
| Professional | | $2,398.83 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $11,748.98
| Facility | | $54.95 | $56.23 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $8,128.31
| Professional | | $6,606.93 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,467.37
| Facility | | $1,258.93 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $2,344.23 / $2,818.38
| Professional | | $10.96 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,630.78
| Facility | | $1,258.93 | $1,819.70 | $3,630.78 |