- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.53 / $4,415.04 / $4,415.04
| Professional | | $2,736.53 | $4,415.04 | $4,415.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,327.68 / $4,623.20 / $4,673.91
| Professional | | $4,327.68 | $4,623.20 | $4,673.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,884.46 / $4,884.46 / $4,884.46
| Facility | | $4,884.46 | $4,884.46 | $4,884.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.00 / $2,046.52 / $5,006.57
| Professional | | $462.00 | $2,046.52 | $5,006.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.53 / $3,622.19 / $4,415.04
| Professional | | $2,736.53 | $3,622.19 | $4,415.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.78 / $3,215.29 / $7,000.47
| Professional | | $1,759.78 | $3,215.29 | $7,000.47 |