- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,391.01 / $4,619.58 / $5,847.60
| Professional | | $4,391.01 | $4,619.58 | $5,847.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,899.36 / $5,470.13 / $5,470.13
| Facility | | $3,899.36 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.96 / $5,470.13 / $5,470.13
| Professional | | $651.96 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,483.80 / $4,619.58 / $5,847.60
| Facility | | $4,483.80 | $4,619.58 | $5,847.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,582.80 / $6,582.80 / $6,582.80
| Professional | | $6,582.80 | $6,582.80 | $6,582.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.97 / $2,924.52 / $4,255.28
| Professional | | $1,929.97 | $2,924.52 | $4,255.28 |