- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.17 / $2,554.17 / $2,554.17
| Professional | | $2,554.17 | $2,554.17 | $2,554.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,768.73 / $3,655.37 / $4,380.54
| Facility | | $1,768.73 | $3,655.37 | $4,380.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.42 / $2,016.83 / $2,299.19
| Facility | | $1,233.42 | $2,016.83 | $2,299.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.91 / $1,413.91 / $3,045.34
| Professional | | $1,413.91 | $1,413.91 | $3,045.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $832.03 / $2,120.86
| Professional | | $30.00 | $832.03 | $2,120.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,171.55 / $3,452.07 / $4,865.83
| Facility | | $2,171.55 | $3,452.07 | $4,865.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.67 / $2,329.82 / $2,449.56
| Professional | | $2,145.67 | $2,329.82 | $2,449.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.75 / $1,392.88 / $2,195.76
| Professional | | $1,188.75 | $1,392.88 | $2,195.76 |