- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $7,413.10
| Professional | | $3,981.07 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,456.54 / $7,585.78
| Facility | | $6,309.57 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $6,456.54 / $10,715.19
| Professional | | $691.83 | $6,456.54 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $912.01 / $4,786.30
| Facility | | $316.23 | $912.01 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $5,128.61
| Professional | | $2,089.30 | $3,090.30 | $5,128.61 |