- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,895.53 / $2,895.53 / $3,664.16
| Professional | | $2,895.53 | $2,895.53 | $3,664.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,604.38 / $3,604.38 / $3,604.38
| Professional | | $3,604.38 | $3,604.38 | $3,604.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,703.96 / $3,248.38 / $3,248.38
| Facility | | $2,703.96 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.13 / $3,248.38 / $3,248.38
| Professional | | $453.13 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,895.53 / $3,177.00 / $5,281.80
| Facility | | $2,895.53 | $3,177.00 | $5,281.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,952.00 / $3,952.00 / $3,952.00
| Professional | | $3,952.00 | $3,952.00 | $3,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.89 / $2,596.26 / $3,546.56
| Professional | | $1,761.89 | $2,596.26 | $3,546.56 |