- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,606.93 / $7,943.28
| Professional | | $5,495.41 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,630.27
| Professional | | $2,187.76 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,019.95
| Facility | | $2,951.21 | $2,951.21 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $3,311.31
| Professional | | $1,348.96 | $1,778.28 | $3,311.31 |