- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,561.45 / $3,776.30 / $4,720.37
| Professional | | $3,561.45 | $3,776.30 | $4,720.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,386.89 / $3,057.10 / $3,974.80
| Facility | | $2,386.89 | $3,057.10 | $3,974.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,426.08 / $8,426.08 / $8,426.08
| Professional | | $8,426.08 | $8,426.08 | $8,426.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,307.00 / $3,307.00 / $3,307.00
| Facility | | $3,307.00 | $3,307.00 | $3,307.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.00 / $2,839.00 / $3,613.46
| Professional | | $2,534.00 | $2,839.00 | $3,613.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.37 / $2,284.66 / $2,284.66
| Professional | | $1,808.37 | $2,284.66 | $2,284.66 |