- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,187.76 / $2,691.53
| Professional | | $2,137.96 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $1,995.26 / $2,818.38
| Facility | | $263.03 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $2,137.96 / $3,019.95
| Professional | | $288.40 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,311.31 / $6,606.93
| Facility | | $977.24 | $3,311.31 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $19,952.62
| Professional | | $2,290.87 | $2,691.53 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $1,949.84 / $3,090.30
| Facility | | $263.03 | $1,949.84 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $3,467.37
| Professional | | $1,698.24 | $2,137.96 | $3,467.37 |