- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.46 / $3,612.02 / $3,822.06
| Professional | | $2,679.46 | $3,612.02 | $3,822.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.75 / $459.71 / $459.71
| Professional | | $390.75 | $459.71 | $459.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $4,124.25
| Facility | | $4,124.25 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,505.61 / $4,124.25 / $4,124.25
| Professional | | $3,505.61 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.74 / $2,723.16 / $3,948.73
| Professional | | $1,860.74 | $2,723.16 | $3,948.73 |