- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.20 / $2,113.92 / $2,113.92
| Professional | | $1,565.20 | $2,113.92 | $2,113.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $1,885.47
| Facility | | $975.26 | $975.26 | $1,885.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.69 / $2,655.00 / $3,318.75
| Professional | | $2,375.69 | $2,655.00 | $3,318.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.97 / $4,288.64 / $10,273.09
| Facility | | $228.97 | $4,288.64 | $10,273.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.78 / $1,550.75 / $1,724.73
| Professional | | $787.78 | $1,550.75 | $1,724.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.42 / $251.87 / $251.87
| Facility | | $209.42 | $251.87 | $251.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.11 / $481.30 / $2,617.32
| Professional | | $251.11 | $481.30 | $2,617.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.80 / $1,550.75 / $1,877.39
| Professional | | $772.80 | $1,550.75 | $1,877.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.73 / $2,060.73 / $2,060.73
| Professional | | $2,060.73 | $2,060.73 | $2,060.73 |