- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,356.40 / $3,393.46 / $3,951.24
| Professional | | $3,356.40 | $3,393.46 | $3,951.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,617.98 / $2,617.98 / $3,741.70
| Professional | | $2,617.98 | $2,617.98 | $3,741.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.05 / $2,673.00 / $3,931.29
| Professional | | $2,272.05 | $2,673.00 | $3,931.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.85 / $3,045.85 / $3,045.85
| Professional | | $3,045.85 | $3,045.85 | $3,045.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.04 / $1,678.96 / $2,964.88
| Professional | | $1,364.04 | $1,678.96 | $2,964.88 |