- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.62 / $2,254.52 / $3,775.61
| Professional | | $1,803.62 | $2,254.52 | $3,775.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,807.05 / $22,807.05 / $22,807.05
| Facility | | $22,807.05 | $22,807.05 | $22,807.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,349.77 / $4,349.77 / $4,349.77
| Professional | | $4,349.77 | $4,349.77 | $4,349.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $971.83 / $1,451.00 / $1,902.89
| Facility | | $971.83 | $1,451.00 | $1,902.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.14 / $1,578.11 / $1,902.89
| Professional | | $1,177.14 | $1,578.11 | $1,902.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,136.70 / $2,131.40
| Professional | | $7.00 | $1,136.70 | $2,131.40 |