- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,661.31 / $6,241.57 / $6,739.65
| Professional | | $5,661.31 | $6,241.57 | $6,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,488.00 / $4,488.00 / $4,978.93
| Facility | | $4,488.00 | $4,488.00 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.09 / $4,232.09 / $4,232.09
| Professional | | $4,232.09 | $4,232.09 | $4,232.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,848.27 / $6,848.27 / $6,848.27
| Professional | | $6,848.27 | $6,848.27 | $6,848.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.19 / $3,413.20 / $4,177.58
| Professional | | $2,185.19 | $3,413.20 | $4,177.58 |