- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,425.44 / $3,561.60 / $4,770.00
| Professional | | $2,425.44 | $3,561.60 | $4,770.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,085.67 / $3,085.67 / $3,085.67
| Professional | | $3,085.67 | $3,085.67 | $3,085.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.51 / $3,360.51 / $3,360.51
| Facility | | $3,360.51 | $3,360.51 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.88 / $1,472.88 / $1,472.88
| Professional | | $1,472.88 | $1,472.88 | $1,472.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.51 / $3,360.51 / $3,360.51
| Facility | | $3,360.51 | $3,360.51 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.26 / $456.54 / $1,644.32
| Professional | | $126.26 | $456.54 | $1,644.32 |