- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,919.28 / $20,530.70 / $20,530.70
| Professional | | $5,919.28 | $20,530.70 | $20,530.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $5,603.67 / $5,603.67
| Facility | | $4,072.36 | $5,603.67 | $5,603.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,556.96 / $5,603.67
| Professional | | $4,072.36 | $4,556.96 | $5,603.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,975.41 / $5,336.83 / $5,603.67
| Facility | | $2,975.41 | $5,336.83 | $5,603.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,205.81 / $6,137.35
| Professional | | $4,072.36 | $4,205.81 | $6,137.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.40 / $2,662.49 / $4,222.68
| Professional | | $2,406.40 | $2,662.49 | $4,222.68 |