- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,913.83 / $2,913.83 / $3,642.29
| Professional | | $2,913.83 | $2,913.83 | $3,642.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,522.00 / $26,542.00 / $34,307.30
| Facility | | $2,522.00 | $26,542.00 | $34,307.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.00 / $2,662.34 / $9,138.90
| Professional | | $2,213.00 | $2,662.34 | $9,138.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,575.35 / $2,041.65 / $2,522.00
| Facility | | $1,575.35 | $2,041.65 | $2,522.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.35 / $2,477.62 / $2,741.01
| Professional | | $1,575.35 | $2,477.62 | $2,741.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $2,460.19 / $2,964.40
| Professional | | $5.00 | $2,460.19 | $2,964.40 |