- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,883.03 / $3,883.03 / $4,853.79
| Professional | | $3,883.03 | $3,883.03 | $4,853.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,453.78 / $6,453.78 / $6,453.78
| Facility | | $6,453.78 | $6,453.78 | $6,453.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,022.00 / $13,549.56 / $13,549.56
| Professional | | $3,022.00 | $13,549.56 | $13,549.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.67 / $2,152.67 / $3,022.00
| Facility | | $2,152.67 | $2,152.67 | $3,022.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.67 / $3,022.00 / $3,710.20
| Professional | | $2,152.67 | $3,022.00 | $3,710.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $2,641.10 / $3,586.70
| Professional | | $11.00 | $2,641.10 | $3,586.70 |