- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,936.64 / $3,281.73 / $3,379.69
| Professional | | $2,936.64 | $3,281.73 | $3,379.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.98 / $3,428.67 / $3,428.67
| Professional | | $2,945.98 | $3,428.67 | $3,428.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $5,707.50
| Professional | | $386.96 | $3,621.85 | $5,707.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.35 / $492.35 / $492.35
| Professional | | $492.35 | $492.35 | $492.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $1,852.20 / $3,413.63
| Professional | | $1,494.94 | $1,852.20 | $3,413.63 |