- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,434.11 / $7,121.66 / $8,115.38
| Professional | | $5,434.11 | $7,121.66 | $8,115.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,971.06 / $6,490.28 / $6,490.28
| Professional | | $5,971.06 | $6,490.28 | $6,490.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $9,791.93
| Facility | | $4,933.43 | $4,933.43 | $9,791.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.57 / $4,933.43 / $11,557.50
| Professional | | $783.57 | $4,933.43 | $11,557.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.65 / $5,391.77 / $7,918.73
| Facility | | $623.65 | $5,391.77 | $7,918.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,343.83 / $5,170.97 / $7,981.54
| Professional | | $3,343.83 | $5,170.97 | $7,981.54 |