- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,561.81 / $12,354.00 / $12,354.00
| Professional | | $3,561.81 | $12,354.00 | $12,354.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,331.07 / $4,331.07 / $4,331.07
| Professional | | $4,331.07 | $4,331.07 | $4,331.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $4,656.77 / $4,656.77
| Facility | | $2,448.80 | $4,656.77 | $4,656.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.80 / $3,786.92 / $4,656.77
| Professional | | $2,448.80 | $3,786.92 | $4,656.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,184.90 / $4,435.02 / $4,656.77
| Facility | | $2,184.90 | $4,435.02 | $4,656.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.80 / $3,495.11 / $4,660.14
| Professional | | $2,448.80 | $3,495.11 | $4,660.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.07 / $1,955.12 / $3,100.81
| Professional | | $1,767.07 | $1,955.12 | $3,100.81 |