- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,360.21 / $18,591.59 / $18,591.59
| Professional | | $5,360.21 | $18,591.59 | $18,591.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $5,074.41 / $5,074.41
| Facility | | $3,578.08 | $5,074.41 | $5,074.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,578.08 / $5,074.41 / $5,074.41
| Professional | | $3,578.08 | $5,074.41 | $5,074.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.38 / $4,832.77 / $5,074.41
| Facility | | $2,694.38 | $4,832.77 | $5,074.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,808.57 / $3,892.98 / $5,557.69
| Professional | | $3,808.57 | $3,892.98 | $5,557.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.12 / $2,411.02 / $3,715.30
| Professional | | $2,179.12 | $2,411.02 | $3,715.30 |