- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.73 / $4,124.27 / $21,745.70
| Professional | | $3,155.73 | $4,124.27 | $21,745.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,639.28 / $6,639.28 / $6,639.28
| Facility | | $6,639.28 | $6,639.28 | $6,639.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,645.05 / $6,389.20 / $11,071.08
| Professional | | $3,645.05 | $6,389.20 | $11,071.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,610.80 / $5,053.05 / $6,929.04
| Facility | | $3,610.80 | $5,053.05 | $6,929.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,126.08 / $6,787.45 / $11,310.32
| Professional | | $4,126.08 | $6,787.45 | $11,310.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,800.72 / $7,137.18 / $11,631.87
| Professional | | $5,800.72 | $7,137.18 | $11,631.87 |