- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.72 / $3,060.72 / $3,060.72
| Professional | | $3,060.72 | $3,060.72 | $3,060.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.15 / $2,344.01 / $2,852.72
| Professional | | $2,241.15 | $2,344.01 | $2,852.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $2,671.66
| Professional | | $286.64 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.23 / $2,862.23 / $2,862.23
| Professional | | $2,862.23 | $2,862.23 | $2,862.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.30 / $2,670.30 / $3,060.72
| Professional | | $2,670.30 | $2,670.30 | $3,060.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.47 / $1,798.50 / $3,807.60
| Professional | | $1,383.47 | $1,798.50 | $3,807.60 |