- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,590.93 / $12,455.00 / $12,455.00
| Professional | | $3,590.93 | $12,455.00 | $12,455.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,366.46 / $4,366.46 / $4,366.46
| Professional | | $4,366.46 | $4,366.46 | $4,366.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $4,694.82 / $4,694.82
| Facility | | $3,060.59 | $4,694.82 | $4,694.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.59 / $4,694.82 / $4,694.82
| Professional | | $3,060.59 | $4,694.82 | $4,694.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.77 / $4,471.26 / $4,694.82
| Facility | | $2,202.77 | $4,471.26 | $4,694.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,477.33 / $3,601.76 / $4,698.22
| Professional | | $3,477.33 | $3,601.76 | $4,698.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.51 / $1,971.11 / $3,037.41
| Professional | | $1,781.51 | $1,971.11 | $3,037.41 |