- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,948.30 / $4,707.08 / $5,384.10
| Professional | | $3,948.30 | $4,707.08 | $5,384.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.66 / $626.04 / $6,273.07
| Facility | | $508.66 | $626.04 | $6,273.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.66 / $547.79 / $6,755.62
| Professional | | $508.66 | $547.79 | $6,755.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $6,464.83
| Facility | | $5,587.01 | $5,587.01 | $6,464.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.05 / $5,587.01 / $5,587.01
| Professional | | $615.05 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.92 / $5,477.92 / $5,477.92
| Professional | | $5,477.92 | $5,477.92 | $5,477.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.44 / $3,130.24 / $4,824.50
| Professional | | $2,255.44 | $3,130.24 | $4,824.50 |