- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,224.40 / $3,443.84 / $4,599.43
| Professional | | $3,224.40 | $3,443.84 | $4,599.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,702.25 / $5,532.06 / $5,532.06
| Professional | | $4,702.25 | $5,532.06 | $5,532.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,900.00 / $5,900.00 / $6,018.00
| Facility | | $5,900.00 | $5,900.00 | $6,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,015.00 / $5,900.00 / $6,018.00
| Professional | | $5,015.00 | $5,900.00 | $6,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,896.89 / $5,001.78 / $8,522.90
| Professional | | $3,896.89 | $5,001.78 | $8,522.90 |