- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,340.21 / $4,991.60 / $17,463.20
| Professional | | $3,340.21 | $4,991.60 | $17,463.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,294.81 / $5,294.81 / $5,294.81
| Facility | | $5,294.81 | $5,294.81 | $5,294.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,710.56 / $5,294.81 / $5,294.81
| Professional | | $4,710.56 | $5,294.81 | $5,294.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,294.81 / $6,672.24 / $6,672.24
| Facility | | $5,294.81 | $6,672.24 | $6,672.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,249.56 / $4,710.56 / $7,031.50
| Professional | | $3,249.56 | $4,710.56 | $7,031.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,180.77 / $6,053.41 / $9,286.96
| Professional | | $5,180.77 | $6,053.41 | $9,286.96 |