- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $2,454.71
| Professional | | $1,737.80 | $2,454.71 | $2,454.71 |
- 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
- $281.84 / $2,398.83 / $5,011.87
| Professional | | $281.84 | $2,398.83 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $2,454.71 / $2,754.23
| Facility | | $331.13 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $363.08 / $1,819.70
| Facility | | $134.90 | $363.08 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $2,238.72
| Professional | | $891.25 | $1,348.96 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,570.40 / $2,570.40
| Facility | | $100.00 | $2,570.40 | $2,570.40 |