- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.24 / $1,905.15 / $1,947.48
| Professional | | $1,665.24 | $1,905.15 | $1,947.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,996.00 / $9,458.00 / $16,848.00
| Facility | | $6,996.00 | $9,458.00 | $16,848.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.06 / $1,113.02 / $1,840.15
| Professional | | $946.06 | $1,113.02 | $1,840.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,175.30 / $5,175.30 / $5,625.32
| Facility | | $5,175.30 | $5,175.30 | $5,625.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.39 / $1,262.88 / $2,058.00
| Professional | | $851.39 | $1,262.88 | $2,058.00 |