- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,948.11 / $2,948.11 / $3,685.14
| Professional | | $2,948.11 | $2,948.11 | $3,685.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,718.20 / $12,718.20 / $12,718.20
| Facility | | $12,718.20 | $12,718.20 | $12,718.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.00 / $6,579.28 / $6,579.28
| Professional | | $2,325.00 | $6,579.28 | $6,579.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.45 / $2,131.21 / $2,526.00
| Facility | | $1,644.45 | $2,131.21 | $2,526.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.00 / $2,676.49 / $3,369.85
| Professional | | $1,814.00 | $2,676.49 | $3,369.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $2,172.10 / $3,000.10
| Professional | | $5.00 | $2,172.10 | $3,000.10 |