- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,521.76 / $6,074.99 / $6,573.53
| Professional | | $5,521.76 | $6,074.99 | $6,573.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $4,933.43
| Facility | | $4,933.43 | $4,933.43 | $4,933.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.42 / $4,193.42 / $4,933.43
| Professional | | $4,193.42 | $4,193.42 | $4,933.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.65 / $5,001.30 / $7,189.03
| Facility | | $623.65 | $5,001.30 | $7,189.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.40 / $4,968.60 / $6,556.54
| Professional | | $3,312.40 | $4,968.60 | $6,556.54 |