- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,398.83 / $3,090.30
| Professional | | $251.19 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $338.84 / $3,715.35
| Facility | | $173.78 | $338.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $2,398.83
| Professional | | $79.43 | $79.43 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $234.42 / $2,137.96
| Facility | | $162.18 | $234.42 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,318.26
| Professional | | $1,148.15 | $1,148.15 | $1,318.26 |