- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $3,162.28
| Professional | | $2,238.72 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $2,238.72 / $6,606.93
| Professional | | $346.74 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,019.95 / $3,388.44
| Facility | | $323.59 | $3,019.95 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $741.31 / $2,187.76
| Facility | | $162.18 | $741.31 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $2,398.83
| Professional | | $1,174.90 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $20,892.96 / $20,892.96
| Facility | | $5,248.07 | $20,892.96 | $20,892.96 |