- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,708.69 / $3,815.60 / $4,393.13
| Professional | | $3,708.69 | $3,815.60 | $4,393.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.17 / $2,976.17 / $3,995.08
| Professional | | $2,976.17 | $2,976.17 | $3,995.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.87 / $3,657.49 / $3,657.49
| Professional | | $3,108.87 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,934.98 / $3,934.98 / $3,934.98
| Professional | | $3,934.98 | $3,934.98 | $3,934.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.68 / $1,866.56 / $3,296.74
| Professional | | $1,550.68 | $1,866.56 | $3,296.74 |