- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,481.30 / $3,519.42 / $4,098.01
| Professional | | $3,481.30 | $3,519.42 | $4,098.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.41 / $2,715.41 / $3,880.32
| Professional | | $2,715.41 | $2,715.41 | $3,880.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.37 / $3,349.85 / $3,349.85
| Professional | | $2,847.37 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,786.75 / $3,786.75 / $3,786.75
| Professional | | $3,786.75 | $3,786.75 | $3,786.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.80 / $1,892.16 / $3,075.03
| Professional | | $1,414.80 | $1,892.16 | $3,075.03 |