- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,570.88 / $5,248.07
| Professional | | $3,548.13 | $4,570.88 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,786.30
| Professional | | $4,073.80 | $4,073.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,128.31 / $10,232.93
| Professional | | $6,606.93 | $8,128.31 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $6,025.60
| Facility | | $5,011.87 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,309.57 / $17,378.01
| Professional | | $2,884.03 | $6,309.57 | $17,378.01 |