- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.42 / $2,757.90 / $3,492.36
| Professional | | $1,357.42 | $2,757.90 | $3,492.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,444.70 / $11,500.00 / $26,542.00
| Facility | | $8,444.70 | $11,500.00 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,948.35 / $4,948.35 / $4,948.35
| Professional | | $4,948.35 | $4,948.35 | $4,948.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,831.50 / $5,250.24 / $30,038.25
| Facility | | $1,831.50 | $5,250.24 | $30,038.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.62 / $901.78 / $1,420.12
| Professional | | $541.62 | $901.78 | $1,420.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $946.00 / $1,865.20
| Professional | | $6.00 | $946.00 | $1,865.20 |