- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,421.16 / $4,731.01 / $4,731.01
| Professional | | $3,421.16 | $4,731.01 | $4,731.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,906.15 / $4,150.28 / $5,273.67
| Professional | | $3,906.15 | $4,150.28 | $5,273.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $3,454.31 / $4,063.89
| Professional | | $3,454.31 | $3,454.31 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,955.25 / $4,731.01 / $4,731.01
| Professional | | $3,955.25 | $4,731.01 | $4,731.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,499.94 / $3,504.45 / $9,726.54
| Professional | | $2,499.94 | $3,504.45 | $9,726.54 |