- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,426.04 / $5,927.74 / $5,927.74
| Professional | | $4,426.04 | $5,927.74 | $5,927.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $4,933.43
| Facility | | $4,933.43 | $4,933.43 | $4,933.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.42 / $4,933.43 / $5,081.43
| Professional | | $4,193.42 | $4,933.43 | $5,081.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $4,933.43
| Facility | | $4,933.43 | $4,933.43 | $4,933.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $5,081.43
| Professional | | $4,933.43 | $4,933.43 | $5,081.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.65 / $5,001.30 / $6,668.40
| Facility | | $623.65 | $5,001.30 | $6,668.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.40 / $6,894.64 / $9,179.15
| Professional | | $3,312.40 | $6,894.64 | $9,179.15 |