- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,079.35 / $5,340.09 / $19,888.30
| Professional | | $4,079.35 | $5,340.09 | $19,888.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,006.21 / $6,006.21 / $6,006.21
| Facility | | $6,006.21 | $6,006.21 | $6,006.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,626.62 / $5,289.22 / $6,006.21
| Professional | | $2,626.62 | $5,289.22 | $6,006.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,959.67 / $4,069.55 / $5,988.51
| Facility | | $2,959.67 | $4,069.55 | $5,988.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,670.75 / $5,650.61 / $7,942.90
| Professional | | $3,670.75 | $5,650.61 | $7,942.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,829.09 / $6,065.38 / $6,989.53
| Professional | | $4,829.09 | $6,065.38 | $6,989.53 |