- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,802.42 / $3,503.03 / $5,866.47
| Professional | | $2,802.42 | $3,503.03 | $5,866.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,807.05 / $22,807.05 / $22,807.05
| Facility | | $22,807.05 | $22,807.05 | $22,807.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,308.29 / $6,308.29 / $6,308.29
| Professional | | $6,308.29 | $6,308.29 | $6,308.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.66 / $2,103.00 / $2,968.79
| Facility | | $1,517.66 | $2,103.00 | $2,968.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.04 / $2,460.29 / $2,968.79
| Professional | | $1,699.04 | $2,460.29 | $2,968.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,767.30 / $3,313.60
| Professional | | $7.00 | $1,767.30 | $3,313.60 |