- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,918.82 / $5,282.70 / $5,589.87
| Professional | | $3,918.82 | $5,282.70 | $5,589.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,900.36 / $6,900.36 / $6,900.36
| Professional | | $6,900.36 | $6,900.36 | $6,900.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,343.04 / $4,343.04 / $4,343.04
| Professional | | $4,343.04 | $4,343.04 | $4,343.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,786.70 / $4,870.84 / $7,091.73
| Professional | | $2,786.70 | $4,870.84 | $7,091.73 |