- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,265.80 / $5,011.87
| Professional | | $3,715.35 | $4,265.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,981.07 / $4,466.84
| Professional | | $3,630.78 | $3,981.07 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,754.40 / $7,585.78
| Professional | | $5,011.87 | $5,754.40 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,801.89
| Facility | | $2,089.30 | $2,089.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $4,073.80
| Professional | | $2,089.30 | $2,238.72 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,981.07 / $3,981.07
| Professional | | $2,511.89 | $3,981.07 | $3,981.07 |