- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $4,466.84
| Professional | | $3,090.30 | $3,890.45 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,073.80
| Professional | | $3,467.37 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $8,709.64
| Professional | | $5,495.41 | $6,918.31 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,128.61
| Facility | | $4,265.80 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,248.07 / $14,791.08
| Professional | | $2,454.71 | $5,248.07 | $14,791.08 |