- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,801.89
| Professional | | $3,019.95 | $3,019.95 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $5,011.87
| Facility | | $2,454.71 | $2,454.71 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $10,471.29
| Professional | | $1,995.26 | $2,691.53 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,691.53
| Professional | | $2,454.71 | $2,454.71 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,884.03
| Professional | | $2,630.27 | $2,630.27 | $2,884.03 |