- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.62 / $2,232.52 / $2,807.44
| Professional | | $2,190.62 | $2,232.52 | $2,807.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,006.39 / $5,006.39 / $5,006.39
| Facility | | $5,006.39 | $5,006.39 | $5,006.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,215.00 / $5,058.00 / $7,651.00
| Professional | | $4,215.00 | $5,058.00 | $7,651.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,061.62 / $4,465.04 / $6,085.08
| Professional | | $3,061.62 | $4,465.04 | $6,085.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $11,831.32 / $18,767.00
| Facility | | $5,188.00 | $11,831.32 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,366.14 / $4,484.95 / $7,950.80
| Professional | | $2,366.14 | $4,484.95 | $7,950.80 |