- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,088.70 / $3,088.70 / $3,279.75
| Professional | | $3,088.70 | $3,088.70 | $3,279.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,950.27 / $2,950.27 / $2,950.27
| Professional | | $2,950.27 | $2,950.27 | $2,950.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,082.75 / $3,626.76
| Professional | | $387.52 | $3,082.75 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,940.14 / $11,060.37 / $14,018.62
| Professional | | $3,940.14 | $11,060.37 | $14,018.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.53 / $1,853.92 / $3,868.78
| Professional | | $1,276.53 | $1,853.92 | $3,868.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,282.07 / $3,636.46 / $4,628.22
| Professional | | $3,282.07 | $3,636.46 | $4,628.22 |