- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,712.62 / $3,899.40 / $4,916.63
| Professional | | $2,712.62 | $3,899.40 | $4,916.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,313.02 / $4,263.49 / $4,393.09
| Professional | | $3,313.02 | $4,263.49 | $4,393.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $1,642.21 / $1,691.48
| Professional | | $513.41 | $1,642.21 | $1,691.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.41 / $5,072.21 / $31,412.20
| Facility | | $1,895.41 | $5,072.21 | $31,412.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.12 / $3,193.58 / $6,000.62
| Professional | | $2,262.12 | $3,193.58 | $6,000.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.44 / $3,193.58 / $6,054.06
| Professional | | $2,432.44 | $3,193.58 | $6,054.06 |