- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.08 / $5,664.06 / $7,080.07
| Professional | | $1,093.08 | $5,664.06 | $7,080.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.34 / $5,291.15 / $5,809.84
| Facility | | $908.34 | $5,291.15 | $5,809.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,070.20 / $17,882.24 / $17,882.24
| Professional | | $5,070.20 | $17,882.24 | $17,882.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,812.00 / $5,812.00 / $5,812.00
| Facility | | $5,812.00 | $5,812.00 | $5,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.10 / $4,988.52 / $6,211.82
| Professional | | $1,023.10 | $4,988.52 | $6,211.82 |