- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,570.88 / $7,244.36
| Professional | | $3,548.13 | $4,570.88 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $13,489.63
| Facility | | $4,786.30 | $4,786.30 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $9,549.93
| Professional | | $4,073.80 | $4,073.80 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,754.40 / $10,232.93
| Facility | | $5,011.87 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,073.80 / $5,888.44
| Professional | | $2,511.89 | $4,073.80 | $5,888.44 |