- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,030.29 / $3,948.84 / $14,862.50
| Professional | | $3,030.29 | $3,948.84 | $14,862.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,482.45 / $4,482.45 / $4,482.45
| Professional | | $4,482.45 | $4,482.45 | $4,482.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,482.45 / $4,482.45 / $4,482.45
| Facility | | $4,482.45 | $4,482.45 | $4,482.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,346.38 / $4,482.45 / $4,831.76
| Professional | | $2,346.38 | $4,482.45 | $4,831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.40 / $3,048.93 / $4,482.45
| Facility | | $2,217.40 | $3,048.93 | $4,482.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.28 / $4,482.45 / $5,917.80
| Professional | | $2,721.28 | $4,482.45 | $5,917.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,885.48 / $4,734.25 / $5,290.87
| Professional | | $3,885.48 | $4,734.25 | $5,290.87 |