- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,912.28 / $2,912.28 / $3,640.34
| Professional | | $2,912.28 | $2,912.28 | $3,640.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,226.72 / $5,226.72 / $5,226.72
| Facility | | $5,226.72 | $5,226.72 | $5,226.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,370.00 / $6,775.00 / $6,775.00
| Professional | | $2,370.00 | $6,775.00 | $6,775.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.81 / $2,079.84 / $2,575.88
| Facility | | $1,604.81 | $2,079.84 | $2,575.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.00 / $2,628.45 / $3,352.18
| Professional | | $2,036.00 | $2,628.45 | $3,352.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $1,629.00 / $2,934.60
| Professional | | $6.00 | $1,629.00 | $2,934.60 |