- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,992.16 / $2,490.19 / $4,170.30
| Professional | | $1,992.16 | $2,490.19 | $4,170.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,851.75 / $13,851.75 / $13,851.75
| Facility | | $13,851.75 | $13,851.75 | $13,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,727.72 / $4,727.72 / $4,727.72
| Professional | | $4,727.72 | $4,727.72 | $4,727.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.15 / $1,578.00 / $2,090.42
| Facility | | $1,066.15 | $1,578.00 | $2,090.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.92 / $1,735.19 / $2,090.42
| Professional | | $1,282.92 | $1,735.19 | $2,090.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,257.00 / $2,356.80
| Professional | | $7.00 | $1,257.00 | $2,356.80 |