- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,143.34 / $4,195.02 / $21,963.00
| Professional | | $3,143.34 | $4,195.02 | $21,963.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,721.83 / $6,721.83 / $6,721.83
| Facility | | $6,721.83 | $6,721.83 | $6,721.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,941.99 / $6,721.83 / $12,174.83
| Professional | | $3,941.99 | $6,721.83 | $12,174.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,147.46 / $5,654.56 / $7,053.64
| Facility | | $4,147.46 | $5,654.56 | $7,053.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,213.55 / $6,845.14 / $11,406.46
| Professional | | $4,213.55 | $6,845.14 | $11,406.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,853.83 / $7,099.34 / $10,711.31
| Professional | | $5,853.83 | $7,099.34 | $10,711.31 |