- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,212.30 / $3,212.30 / $3,212.30
| Professional | | $3,212.30 | $3,212.30 | $3,212.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,946.00 / $9,472.00 / $17,487.00
| Facility | | $5,946.00 | $9,472.00 | $17,487.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.63 / $836.53 / $1,211.69
| Professional | | $676.63 | $836.53 | $1,211.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $703.97 / $865.06 / $1,182.67
| Facility | | $703.97 | $865.06 | $1,182.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.32 / $918.75 / $1,181.25
| Professional | | $644.32 | $918.75 | $1,181.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.48 / $1,004.71 / $1,657.43
| Professional | | $795.48 | $1,004.71 | $1,657.43 |