- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $7,244.36
| Professional | | $3,090.30 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Professional | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.03 / $5,011.87 / $5,754.40
| Facility | | $6.03 | $5,011.87 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,128.61 / $6,456.54
| Professional | | $3,890.45 | $5,128.61 | $6,456.54 |