- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,652.23 / $6,231.57 / $6,728.85
| Professional | | $5,652.23 | $6,231.57 | $6,728.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.57 / $775.57 / $4,321.80
| Facility | | $775.57 | $775.57 | $4,321.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,673.53 / $3,673.53 / $3,673.53
| Professional | | $3,673.53 | $3,673.53 | $3,673.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,837.35 / $6,837.35 / $6,837.35
| Professional | | $6,837.35 | $6,837.35 | $6,837.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.69 / $3,407.76 / $4,170.97
| Professional | | $2,181.69 | $3,407.76 | $4,170.97 |