- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,056.36 / $13,966.00 / $13,966.00
| Professional | | $3,056.36 | $13,966.00 | $13,966.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,260.03 / $4,260.03 / $4,260.03
| Facility | | $4,260.03 | $4,260.03 | $4,260.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,143.94 / $4,260.03 / $4,260.03
| Professional | | $3,143.94 | $4,260.03 | $4,260.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,260.03 / $4,901.64 / $5,219.39
| Facility | | $4,260.03 | $4,901.64 | $5,219.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.06 / $3,694.81 / $5,643.40
| Professional | | $2,608.06 | $3,694.81 | $5,643.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,845.92 / $4,756.80 / $10,798.93
| Professional | | $3,845.92 | $4,756.80 | $10,798.93 |