- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.54 / $2,263.54 / $2,829.42
| Professional | | $2,263.54 | $2,263.54 | $2,829.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,858.40 / $17,858.40 / $17,858.40
| Facility | | $17,858.40 | $17,858.40 | $17,858.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,405.00 / $3,405.00 / $3,405.00
| Professional | | $3,405.00 | $3,405.00 | $3,405.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,568.76 / $5,146.54 / $5,586.57
| Facility | | $4,568.76 | $5,146.54 | $5,586.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,652.81 / $5,348.06 / $9,263.77
| Professional | | $3,652.81 | $5,348.06 | $9,263.77 |