- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,311.31 / $4,168.69
| Professional | | $1,949.84 | $3,311.31 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,309.57
| Facility | | $3,467.37 | $3,467.37 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $3,467.37 / $7,413.10
| Professional | | $501.19 | $3,467.37 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,466.84 / $33,113.11
| Facility | | $1,995.26 | $4,466.84 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $4,897.79
| Professional | | $2,089.30 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $2,691.53 / $4,897.79
| Facility | | $288.40 | $2,691.53 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $4,897.79
| Professional | | $2,570.40 | $3,311.31 | $4,897.79 |