- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,152.58 / $8,145.01 / $8,327.50
| Professional | | $6,152.58 | $8,145.01 | $8,327.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,129.43 / $5,129.43 / $6,669.51
| Professional | | $5,129.43 | $5,129.43 | $6,669.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,245.86 / $3,818.66 / $3,818.66
| Professional | | $3,245.86 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,628.80 / $4,628.80 / $4,628.80
| Professional | | $4,628.80 | $4,628.80 | $4,628.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.54 / $3,367.64 / $4,520.64
| Professional | | $2,276.54 | $3,367.64 | $4,520.64 |