- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.13 / $1,207.13 / $2,609.37
| Professional | | $1,207.13 | $1,207.13 | $2,609.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,703.29 / $8,703.29 / $10,443.95
| Facility | | $8,703.29 | $8,703.29 | $10,443.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.48 / $949.23 / $1,916.70
| Professional | | $645.48 | $949.23 | $1,916.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,356.00 / $3,356.00 / $3,356.00
| Facility | | $3,356.00 | $3,356.00 | $3,356.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.42 / $1,210.15 / $2,296.84
| Professional | | $960.42 | $1,210.15 | $2,296.84 |