- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,197.84 / $3,728.45 / $18,493.90
| Professional | | $3,197.84 | $3,728.45 | $18,493.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,611.34 / $5,611.34 / $5,611.34
| Facility | | $5,611.34 | $5,611.34 | $5,611.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,206.59 / $5,611.34 / $10,386.65
| Professional | | $3,206.59 | $5,611.34 | $10,386.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,539.96 / $4,545.71 / $6,892.35
| Facility | | $2,539.96 | $4,545.71 | $6,892.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,707.39 / $5,741.40 / $9,567.23
| Professional | | $3,707.39 | $5,741.40 | $9,567.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,973.42 / $6,128.65 / $9,842.92
| Professional | | $4,973.42 | $6,128.65 | $9,842.92 |