- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.22 / $3,866.20 / $4,284.17
| Professional | | $3,657.22 | $3,866.20 | $4,284.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,538.18 / $6,153.53 / $6,426.26
| Facility | | $5,538.18 | $6,153.53 | $6,426.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,922.60 / $6,922.60 / $6,922.60
| Professional | | $6,922.60 | $6,922.60 | $6,922.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,269.52 / $6,269.52 / $6,269.52
| Facility | | $6,269.52 | $6,269.52 | $6,269.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $7,535.44
| Professional | | $2,194.33 | $3,134.76 | $7,535.44 |