- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,283.53 / $4,283.53 / $5,420.48
| Professional | | $4,283.53 | $4,283.53 | $5,420.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,650.00 / $4,880.32 / $5,862.42
| Professional | | $4,650.00 | $4,880.32 | $5,862.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $5,076.82
| Facility | | $4,775.22 | $4,775.22 | $5,076.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.53 / $4,775.22 / $4,775.22
| Professional | | $671.53 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,283.53 / $4,709.85 / $7,774.00
| Facility | | $4,283.53 | $4,709.85 | $7,774.00 |
- 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
- $2,590.17 / $3,840.72 / $5,233.52
| Professional | | $2,590.17 | $3,840.72 | $5,233.52 |