- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,354.28 / $4,221.18 / $4,553.20
| Professional | | $3,354.28 | $4,221.18 | $4,553.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,413.52 / $5,192.38 / $6,942.40
| Professional | | $4,413.52 | $5,192.38 | $6,942.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,391.66 / $4,391.66 / $4,391.66
| Facility | | $4,391.66 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,732.91 / $4,391.66 / $4,391.66
| Professional | | $3,732.91 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,461.59 / $4,675.09 / $6,383.28
| Professional | | $3,461.59 | $4,675.09 | $6,383.28 |