- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.24 / $6,495.92 / $6,689.83
| Professional | | $4,168.24 | $6,495.92 | $6,689.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.88 / $5,652.72 / $6,786.78
| Professional | | $4,193.88 | $5,652.72 | $6,786.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $12,836.25
| Professional | | $782.55 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.24 / $1,107.24 / $1,107.24
| Professional | | $1,107.24 | $1,107.24 | $1,107.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.92 / $3,130.20 / $5,217.00
| Professional | | $2,121.92 | $3,130.20 | $5,217.00 |