- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.87 / $4,523.43 / $4,523.43
| Professional | | $2,792.87 | $4,523.43 | $4,523.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.54 / $201.54 / $251.93
| Facility | | $201.54 | $201.54 | $251.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,930.04 / $5,240.06 / $8,711.59
| Professional | | $3,930.04 | $5,240.06 | $8,711.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $7,331.25
| Professional | | $408.57 | $3,655.97 | $7,331.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $595.19 / $3,277.73 / $26,705.78
| Facility | | $595.19 | $3,277.73 | $26,705.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.44 / $1,878.68 / $2,974.57
| Professional | | $1,296.44 | $1,878.68 | $2,974.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.78 / $1,878.68 / $2,974.57
| Professional | | $1,486.78 | $1,878.68 | $2,974.57 |