- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,973.41 / $3,973.41 / $4,966.76
| Professional | | $3,973.41 | $3,973.41 | $4,966.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $3,397.00 / $6,610.74
| Facility | | $55.00 | $3,397.00 | $6,610.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,956.00 / $3,662.78 / $12,098.52
| Professional | | $2,956.00 | $3,662.78 | $12,098.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,055.19 / $2,663.54 / $3,397.00
| Facility | | $2,055.19 | $2,663.54 | $3,397.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.46 / $3,258.00 / $3,824.96
| Professional | | $1,881.46 | $3,258.00 | $3,824.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $3,342.90 / $4,028.00
| Professional | | $11.00 | $3,342.90 | $4,028.00 |