- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,998.28 / $8,259.65 / $8,767.50
| Professional | | $5,998.28 | $8,259.65 | $8,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,662.05 / $4,662.05 / $5,035.50
| Professional | | $4,662.05 | $4,662.05 | $5,035.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,467.38 / $7,608.68 / $7,608.68
| Professional | | $6,467.38 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,788.05 / $3,692.36 / $4,736.06
| Professional | | $2,788.05 | $3,692.36 | $4,736.06 |