- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $2,754.23
| Professional | | $1,479.11 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $2,398.83
| Facility | | $2,344.23 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,398.83 / $3,981.07
| Professional | | $251.19 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $331.13 / $1,862.09
| Facility | | $128.82 | $331.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $2,137.96
| Professional | | $776.25 | $1,202.26 | $2,137.96 |