- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,277.78 / $4,253.33 / $21,186.10
| Professional | | $3,277.78 | $4,253.33 | $21,186.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.42 / $6,652.42 / $6,652.42
| Facility | | $6,652.42 | $6,652.42 | $6,652.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,939.06 / $6,652.42 / $6,652.42
| Professional | | $3,939.06 | $6,652.42 | $6,652.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,281.22 / $6,559.03 / $6,652.42
| Facility | | $3,281.22 | $6,559.03 | $6,652.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,025.63 / $5,754.82 / $8,710.79
| Professional | | $4,025.63 | $5,754.82 | $8,710.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,508.26 / $7,039.45 / $11,642.95
| Professional | | $5,508.26 | $7,039.45 | $11,642.95 |