- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,854.28 / $20,305.30 / $20,305.30
| Professional | | $5,854.28 | $20,305.30 | $20,305.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $7,753.37 / $7,753.37
| Facility | | $4,697.47 | $7,753.37 | $7,753.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,697.47 / $7,753.37 / $7,753.37
| Professional | | $4,697.47 | $7,753.37 | $7,753.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,923.64 / $7,384.16 / $7,753.37
| Facility | | $3,923.64 | $7,384.16 | $7,753.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,819.24 / $5,948.20 / $8,021.66
| Professional | | $5,819.24 | $5,948.20 | $8,021.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,173.29 / $3,511.00 / $5,410.34
| Professional | | $3,173.29 | $3,511.00 | $5,410.34 |