- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,365.16 / $4,365.16
| Professional | | $3,311.31 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $3,467.37 / $9,120.11
| Professional | | $549.54 | $3,467.37 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,715.35 / $3,715.35
| Professional | | $3,388.44 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,365.16 / $6,309.57
| Facility | | $2,137.96 | $4,365.16 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $2,137.96 / $4,265.80
| Facility | | $269.15 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $5,248.07
| Professional | | $2,187.76 | $3,162.28 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $34,673.69 / $34,673.69
| Facility | | $5,248.07 | $34,673.69 | $34,673.69 |