- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.58 / $2,231.25 / $2,231.25
| Professional | | $1,665.58 | $2,231.25 | $2,231.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,387.48 / $2,387.48
| Professional | | $251.77 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.90 / $491.61 / $4,328.28
| Professional | | $208.90 | $491.61 | $4,328.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,752.08 / $1,885.56 / $2,765.49
| Facility | | $1,752.08 | $1,885.56 | $2,765.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,387.48 / $2,387.48
| Professional | | $251.77 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.48 / $1,226.35 / $1,982.00
| Professional | | $1,141.48 | $1,226.35 | $1,982.00 |