- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,237.14 / $4,237.14 / $7,420.38
| Professional | | $4,237.14 | $4,237.14 | $7,420.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,275.66 / $8,275.66 / $8,275.66
| Facility | | $8,275.66 | $8,275.66 | $8,275.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,275.66 / $8,275.66 / $8,275.66
| Professional | | $8,275.66 | $8,275.66 | $8,275.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $9,102.84
| Facility | | $4,751.45 | $4,751.45 | $9,102.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,038.73 / $4,751.45
| Professional | | $4,038.73 | $4,038.73 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,428.69 / $3,793.57 / $5,845.78
| Professional | | $3,428.69 | $3,793.57 | $5,845.78 |