- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,447.55 / $4,591.50 / $4,614.38
| Professional | | $3,447.55 | $4,591.50 | $4,614.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,465.34 / $4,393.09 / $4,393.09
| Professional | | $3,465.34 | $4,393.09 | $4,393.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.88 / $1,642.21 / $1,642.21
| Professional | | $1,395.88 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,101.86 / $3,101.86 / $3,101.86
| Professional | | $3,101.86 | $3,101.86 | $3,101.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.52 / $3,007.26 / $4,292.18
| Professional | | $2,260.52 | $3,007.26 | $4,292.18 |