- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,244.36 / $7,762.47
| Professional | | $5,128.61 | $7,244.36 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,709.64
| Facility | | $8,128.31 | $8,128.31 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $8,128.31
| Professional | | $5,888.44 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $11,748.98 / $15,848.93
| Professional | | $9,332.54 | $11,748.98 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,025.60 / $9,549.93
| Facility | | $5,011.87 | $6,025.60 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $8,912.51 / $25,118.86
| Professional | | $4,168.69 | $8,912.51 | $25,118.86 |