- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,879.45 / $5,765.80 / $6,144.92
| Professional | | $4,879.45 | $5,765.80 | $6,144.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,917.60 / $3,917.60 / $3,957.11
| Professional | | $3,917.60 | $3,917.60 | $3,957.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $5,587.01
| Facility | | $5,587.01 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,748.96 / $5,587.01 / $6,653.09
| Professional | | $4,748.96 | $5,587.01 | $6,653.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.40 / $2,895.28 / $3,979.78
| Professional | | $2,050.40 | $2,895.28 | $3,979.78 |