- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.54 / $3,221.19 / $3,408.57
| Professional | | $2,389.54 | $3,221.19 | $3,408.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.47 / $409.97 / $409.97
| Professional | | $348.47 | $409.97 | $409.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,078.57 / $3,621.85 / $3,621.85
| Professional | | $3,078.57 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.40 / $2,075.48 / $3,499.47
| Professional | | $1,659.40 | $2,075.48 | $3,499.47 |