- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,792.33 / $3,792.33 / $3,792.33
| Professional | | $3,792.33 | $3,792.33 | $3,792.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,702.47 / $4,702.47 / $4,945.18
| Professional | | $4,702.47 | $4,702.47 | $4,945.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,822.66 / $3,822.66 / $3,822.66
| Facility | | $3,822.66 | $3,822.66 | $3,822.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.72 / $3,200.72 / $3,640.63
| Professional | | $3,200.72 | $3,200.72 | $3,640.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,274.22 / $1,820.32
| Professional | | $1,274.22 | $1,274.22 | $1,820.32 |