- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,689.35 / $3,782.40 / $4,363.39
| Professional | | $3,689.35 | $3,782.40 | $4,363.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,950.27 / $2,950.27 / $3,982.62
| Professional | | $2,950.27 | $2,950.27 | $3,982.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,082.75 / $3,626.76 / $3,626.76
| Professional | | $3,082.75 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,886.74 / $3,886.74 / $3,886.74
| Professional | | $3,886.74 | $3,886.74 | $3,886.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.16 / $1,983.52 / $3,224.16
| Professional | | $1,537.16 | $1,983.52 | $3,224.16 |