- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,011.87 / $5,888.44
| Professional | | $3,890.45 | $5,011.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,890.45 / $6,309.57
| Professional | | $3,715.35 | $3,890.45 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,623.41 / $5,623.41
| Facility | | $4,168.69 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $4,786.30 / $5,623.41
| Professional | | $660.69 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $4,365.16 / $6,918.31
| Facility | | $363.08 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,951.21 / $5,623.41
| Professional | | $2,089.30 | $2,951.21 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $831.76 / $4,168.69
| Facility | | $288.40 | $831.76 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $4,677.35
| Professional | | $2,089.30 | $2,818.38 | $4,677.35 |