- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,241.84 / $4,052.29 / $6,786.32
| Professional | | $3,241.84 | $4,052.29 | $6,786.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,347.80 / $6,347.80 / $6,347.80
| Facility | | $6,347.80 | $6,347.80 | $6,347.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,001.20 / $11,001.20 / $11,001.20
| Professional | | $11,001.20 | $11,001.20 | $11,001.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,265.17 / $2,703.34 / $3,434.16
| Facility | | $2,265.17 | $2,703.34 | $3,434.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.00 / $2,882.40 / $3,702.78
| Professional | | $2,175.00 | $2,882.40 | $3,702.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,997.90 / $3,958.00
| Professional | | $7.00 | $1,997.90 | $3,958.00 |