- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,224.69 / $5,258.82 / $8,916.87
| Professional | | $3,224.69 | $5,258.82 | $8,916.87 |
- 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
- $3,343.83 / $7,335.98 / $54,554.97
| Facility | | $3,343.83 | $7,335.98 | $54,554.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,511.03 / $5,507.49 / $7,918.73
| Professional | | $3,511.03 | $5,507.49 | $7,918.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.91 / $4,388.79 / $7,866.95
| Facility | | $470.91 | $4,388.79 | $7,866.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,140.50 / $5,461.60 / $7,866.95
| Professional | | $4,140.50 | $5,461.60 | $7,866.95 |