- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,069.19 / $3,906.14 / $4,166.20
| Professional | | $3,069.19 | $3,906.14 | $4,166.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,137.83 / $3,691.57 / $6,173.88
| Professional | | $3,137.83 | $3,691.57 | $6,173.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $4,063.89 / $4,063.89
| Professional | | $3,454.31 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,167.37 / $4,011.62 / $5,840.75
| Professional | | $3,167.37 | $4,011.62 | $5,840.75 |