- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,439.61 / $5,718.50 / $6,505.46
| Professional | | $5,439.61 | $5,718.50 | $6,505.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,388.00 / $4,388.00 / $5,781.54
| Professional | | $4,388.00 | $4,388.00 | $5,781.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,649.60 / $5,470.13 / $5,470.13
| Professional | | $4,649.60 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,642.37 / $5,642.37 / $5,642.37
| Professional | | $5,642.37 | $5,642.37 | $5,642.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.96 / $2,924.52 / $4,680.54
| Professional | | $2,323.96 | $2,924.52 | $4,680.54 |