- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,117.32 / $3,430.38 / $4,287.97
| Professional | | $3,117.32 | $3,430.38 | $4,287.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,576.00 / $5,827.20
| Facility | | $55.00 | $2,576.00 | $5,827.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.00 / $7,454.23 / $7,454.23
| Professional | | $2,152.00 | $7,454.23 | $7,454.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.68 / $2,411.42 / $2,576.00
| Facility | | $1,860.68 | $2,411.42 | $2,576.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.68 / $2,576.00 / $3,292.68
| Professional | | $1,860.68 | $2,576.00 | $3,292.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $2,179.40 / $3,445.10
| Professional | | $7.00 | $2,179.40 | $3,445.10 |