- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,762.47 / $8,317.64
| Professional | | $7,079.46 | $7,762.47 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $5,128.61
| Professional | | $4,365.16 | $4,365.16 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $812.83 / $5,370.32
| Facility | | $426.58 | $812.83 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,265.80 / $6,456.54
| Professional | | $3,019.95 | $4,265.80 | $6,456.54 |