- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.54 / $2,444.42 / $4,093.64
| Professional | | $1,955.54 | $2,444.42 | $4,093.64 |
- 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
- $4,365.45 / $4,365.45 / $4,365.45
| Professional | | $4,365.45 | $4,365.45 | $4,365.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,054.64 / $1,457.00 / $2,063.48
| Facility | | $1,054.64 | $1,457.00 | $2,063.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.94 / $1,713.88 / $2,063.48
| Professional | | $1,180.94 | $1,713.88 | $2,063.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,233.59 / $2,313.00
| Professional | | $7.00 | $1,233.59 | $2,313.00 |