- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $8,128.31 / $12,302.69
| Professional | | $5,370.32 | $8,128.31 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,128.61 / $5,248.07
| Professional | | $4,365.16 | $5,128.61 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $724.44 / $4,786.30
| Facility | | $630.96 | $724.44 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,801.89 / $7,079.46
| Professional | | $2,818.38 | $3,801.89 | $7,079.46 |