- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,999.73 / $4,810.89 / $5,429.35
| Professional | | $3,999.73 | $4,810.89 | $5,429.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,942.78 / $17,480.90 / $20,695.34
| Facility | | $12,942.78 | $17,480.90 | $20,695.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,810.81 / $4,810.81 / $8,045.70
| Professional | | $4,810.81 | $4,810.81 | $8,045.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,294.99 / $6,541.83 / $6,541.83
| Facility | | $5,294.99 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $6,541.83
| Professional | | $4,775.54 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,680.11 / $10,680.11 / $10,680.11
| Facility | | $10,680.11 | $10,680.11 | $10,680.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,127.68 / $5,227.88 / $7,611.57
| Professional | | $4,127.68 | $5,227.88 | $7,611.57 |