- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.75 / $2,760.94 / $4,623.70
| Professional | | $2,208.75 | $2,760.94 | $4,623.70 |
- 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
- $5,235.97 / $5,235.97 / $5,235.97
| Professional | | $5,235.97 | $5,235.97 | $5,235.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.83 / $1,747.00 / $2,323.37
| Facility | | $1,185.83 | $1,747.00 | $2,323.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.54 / $1,927.14 / $2,323.37
| Professional | | $1,416.54 | $1,927.14 | $2,323.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,393.00 / $2,611.90
| Professional | | $7.00 | $1,393.00 | $2,611.90 |