- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,175.04 / $17,949.30 / $17,949.30
| Professional | | $5,175.04 | $17,949.30 | $17,949.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $5,764.48 / $5,764.48
| Facility | | $3,798.08 | $5,764.48 | $5,764.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,798.08 / $4,687.72 / $5,764.48
| Professional | | $3,798.08 | $4,687.72 | $5,764.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,621.06 / $5,489.98 / $5,764.48
| Facility | | $2,621.06 | $5,489.98 | $5,764.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,798.08 / $4,326.50 / $5,966.31
| Professional | | $3,798.08 | $4,326.50 | $5,966.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.82 / $2,345.41 / $3,719.80
| Professional | | $2,119.82 | $2,345.41 | $3,719.80 |