- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,248.07 / $5,248.07
| Professional | | $4,897.79 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $7,413.10
| Facility | | $2,238.72 | $2,691.53 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,248.07 / $5,248.07
| Professional | | $5,128.61 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,248.07 / $5,248.07
| Facility | | $2,344.23 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $9,332.54
| Professional | | $5,248.07 | $5,248.07 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $6,309.57
| Professional | | $5,248.07 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,248.07 / $6,165.95
| Professional | | $4,897.79 | $5,248.07 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,248.07 / $7,413.10
| Professional | | $5,128.61 | $5,248.07 | $7,413.10 |