- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,434.11 / $6,210.75 / $7,800.58
| Professional | | $5,434.11 | $6,210.75 | $7,800.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.83 / $1,288.83 / $1,288.83
| Facility | | $1,288.83 | $1,288.83 | $1,288.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.40 / $798.40 / $798.40
| Professional | | $798.40 | $798.40 | $798.40 |
- 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 / $4,933.43
| Professional | | $783.57 | $4,933.43 | $4,933.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.65 / $5,001.30 / $7,918.73
| Facility | | $623.65 | $5,001.30 | $7,918.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.40 / $4,968.60 / $10,005.27
| Professional | | $3,312.40 | $4,968.60 | $10,005.27 |