- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,277.75 / $3,277.75 / $4,147.76
| Professional | | $3,277.75 | $3,277.75 | $4,147.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.00 / $3,675.00 / $4,412.57
| Professional | | $3,500.00 | $3,675.00 | $4,412.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $4,198.50
| Facility | | $1,642.21 | $1,642.21 | $4,198.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $1,642.21 / $1,642.21
| Professional | | $513.41 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,277.75 / $3,600.15 / $5,967.30
| Facility | | $3,277.75 | $3,600.15 | $5,967.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,490.00 / $3,490.00 / $3,490.00
| Professional | | $3,490.00 | $3,490.00 | $3,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,988.19 / $2,938.92 / $4,162.47
| Professional | | $1,988.19 | $2,938.92 | $4,162.47 |