- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,025.62 / $5,426.69 / $5,742.22
| Professional | | $4,025.62 | $5,426.69 | $5,742.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,088.49 / $7,088.49 / $7,088.49
| Professional | | $7,088.49 | $7,088.49 | $7,088.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,861.89 / $8,072.81 / $8,072.81
| Professional | | $6,861.89 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.67 / $4,371.04 / $7,285.07
| Professional | | $2,862.67 | $4,371.04 | $7,285.07 |