- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,754.40 / $6,456.54
| Professional | | $4,570.88 | $5,754.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $4,466.84
| Professional | | $3,548.13 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $16,982.44 / $16,982.44
| Facility | | $4,570.88 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $15,848.93 / $15,848.93
| Professional | | $3,388.44 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,548.13 / $4,073.80
| Professional | | $3,162.28 | $3,548.13 | $4,073.80 |