- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $6,025.60
| Professional | | $5,011.87 | $5,623.41 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,090.30
| Professional | | $2,630.27 | $2,630.27 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $588.84 / $3,890.45
| Facility | | $309.03 | $588.84 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $4,570.88
| Professional | | $2,137.96 | $3,019.95 | $4,570.88 |