- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,402.63 / $7,152.22 / $7,312.40
| Professional | | $5,402.63 | $7,152.22 | $7,312.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,504.27 / $4,504.27 / $5,856.70
| Professional | | $4,504.27 | $4,504.27 | $5,856.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $3,087.00
| Facility | | $3,087.00 | $3,087.00 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,623.95 / $3,087.00 / $3,790.53
| Professional | | $2,623.95 | $3,087.00 | $3,790.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,064.62 / $4,064.62 / $4,064.62
| Professional | | $4,064.62 | $4,064.62 | $4,064.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,329.41 / $3,052.36 / $3,969.60
| Professional | | $2,329.41 | $3,052.36 | $3,969.60 |