- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,495.41 / $6,606.93
| Professional | | $3,981.07 | $5,495.41 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,244.36
| Facility | | $6,606.93 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,606.93
| Professional | | $4,786.30 | $4,786.30 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $9,772.37 / $12,022.64
| Professional | | $7,762.47 | $9,772.37 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,677.35 / $7,244.36
| Facility | | $3,981.07 | $4,677.35 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,413.10 / $20,892.96
| Professional | | $3,467.37 | $7,413.10 | $20,892.96 |