- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,633.37 / $6,011.98 / $10,407.00
| Professional | | $5,633.37 | $6,011.98 | $10,407.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,671.68 / $5,671.68 / $11,717.20
| Facility | | $5,671.68 | $5,671.68 | $11,717.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $5,671.68
| Professional | | $5,168.22 | $5,168.22 | $5,671.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,671.68 / $5,671.68 / $11,717.20
| Facility | | $5,671.68 | $5,671.68 | $11,717.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,607.04 / $7,313.54
| Professional | | $5,168.22 | $5,607.04 | $7,313.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $5,168.22
| Professional | | $5,168.22 | $5,168.22 | $5,168.22 |