- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,535.76 / $3,641.83 / $4,031.95
| Professional | | $3,535.76 | $3,641.83 | $4,031.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,497.21 / $4,090.38 / $4,090.38
| Professional | | $3,497.21 | $4,090.38 | $4,090.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.38 / $4,303.28 / $6,776.25
| Professional | | $459.38 | $4,303.28 | $6,776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.48 / $584.48 / $584.48
| Professional | | $584.48 | $584.48 | $584.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.23 / $2,209.71 / $3,816.15
| Professional | | $1,513.23 | $2,209.71 | $3,816.15 |