- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.37 / $2,966.24 / $5,100.18
| Professional | | $739.37 | $2,966.24 | $5,100.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $544.54 / $4,341.83 / $4,824.26
| Facility | | $544.54 | $4,341.83 | $4,824.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,909.00 / $11,564.19 / $11,564.19
| Professional | | $4,909.00 | $11,564.19 | $11,564.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,118.00 / $4,118.00 / $4,118.00
| Facility | | $4,118.00 | $4,118.00 | $4,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.60 / $2,890.00 / $4,180.00
| Professional | | $2,178.60 | $2,890.00 | $4,180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.16 / $3,094.21 / $3,145.94
| Professional | | $2,288.16 | $3,094.21 | $3,145.94 |