- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,781.51 / $3,781.51 / $4,942.93
| Professional | | $3,781.51 | $3,781.51 | $4,942.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,950.27 / $3,982.62 / $3,982.62
| Professional | | $2,950.27 | $3,982.62 | $3,982.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,650.37
| Facility | | $3,626.76 | $3,626.76 | $3,650.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,626.76 / $3,741.62
| Professional | | $387.52 | $3,626.76 | $3,741.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,940.14 / $3,940.14 / $3,940.14
| Professional | | $3,940.14 | $3,940.14 | $3,940.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,279.75 / $3,781.51 / $4,942.93
| Professional | | $3,279.75 | $3,781.51 | $4,942.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.53 / $2,975.28 / $5,785.27
| Professional | | $1,276.53 | $2,975.28 | $5,785.27 |