- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.08 / $2,337.98 / $4,856.21
| Professional | | $1,678.08 | $2,337.98 | $4,856.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,107.57 / $3,655.97 / $5,865.00
| Professional | | $3,107.57 | $3,655.97 | $5,865.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,814.00 / $5,814.00 / $5,814.00
| Professional | | $5,814.00 | $5,814.00 | $5,814.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,365.28 / $3,365.28 / $3,365.28
| Professional | | $3,365.28 | $3,365.28 | $3,365.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.84 / $2,235.63 / $4,110.37
| Professional | | $1,583.84 | $2,235.63 | $4,110.37 |