- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $2,951.21
| Professional | | $1,380.38 | $2,398.83 | $2,951.21 |
- 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 / $5,248.07
| Professional | | $346.74 | $2,238.72 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $1,230.27 / $20,417.38
| Facility | | $275.42 | $1,230.27 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,659.59 / $2,754.23
| Professional | | $954.99 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $467.74 / $2,290.87
| Facility | | $177.83 | $467.74 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $2,754.23
| Professional | | $1,202.26 | $1,737.80 | $2,754.23 |