- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,048.91 / $4,051.70 / $4,076.38
| Professional | | $3,048.91 | $4,051.70 | $4,076.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,070.92 / $3,893.06 / $3,893.06
| Professional | | $3,070.92 | $3,893.06 | $3,893.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.12 / $3,248.38 / $3,248.38
| Professional | | $2,761.12 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,513.04 / $3,513.04 / $3,513.04
| Professional | | $3,513.04 | $3,513.04 | $3,513.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.92 / $2,659.92 / $3,803.63
| Professional | | $1,996.92 | $2,659.92 | $3,803.63 |