- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,861.33 / $6,830.77 / $7,232.58
| Professional | | $3,861.33 | $6,830.77 | $7,232.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,842.59 / $4,842.59 / $4,842.59
| Professional | | $4,842.59 | $4,842.59 | $4,842.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $3,087.00
| Facility | | $3,087.00 | $3,087.00 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.63 / $3,087.00 / $10,638.75
| Professional | | $648.63 | $3,087.00 | $10,638.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.68 / $2,880.45 / $4,202.09
| Professional | | $1,729.68 | $2,880.45 | $4,202.09 |