- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.98 / $5,420.48 / $5,420.48
| Professional | | $3,870.98 | $5,420.48 | $5,420.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,807.31 / $4,775.22 / $4,775.22
| Facility | | $3,807.31 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.53 / $4,775.22 / $11,264.06
| Professional | | $671.53 | $4,775.22 | $11,264.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.78 / $5,420.48 / $6,778.49
| Facility | | $2,592.78 | $5,420.48 | $6,778.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,810.00 / $5,810.00 / $5,810.00
| Professional | | $5,810.00 | $5,810.00 | $5,810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.35 / $3,925.14 / $7,385.40
| Professional | | $2,652.35 | $3,925.14 | $7,385.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,120.95 / $42,533.64 / $42,533.64
| Facility | | $7,120.95 | $42,533.64 | $42,533.64 |