- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,876.98 / $3,641.83 / $4,103.83
| Professional | | $2,876.98 | $3,641.83 | $4,103.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.56 / $493.60 / $493.60
| Professional | | $419.56 | $493.60 | $493.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.79 / $4,303.28 / $4,303.28
| Professional | | $3,657.79 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.90 / $2,514.44 / $4,190.72
| Professional | | $1,997.90 | $2,514.44 | $4,190.72 |