- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,224.69 / $4,347.01 / $4,599.76
| Professional | | $3,224.69 | $4,347.01 | $4,599.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,702.68 / $5,532.56 / $5,532.56
| Professional | | $4,702.68 | $5,532.56 | $5,532.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $4,933.43
| Facility | | $4,933.43 | $4,933.43 | $4,933.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.42 / $4,933.43 / $4,933.43
| Professional | | $4,193.42 | $4,933.43 | $4,933.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.65 / $5,001.30 / $6,668.40
| Facility | | $623.65 | $5,001.30 | $6,668.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,897.24 / $5,825.28 / $10,351.25
| Professional | | $3,897.24 | $5,825.28 | $10,351.25 |