- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,233.34 / $7,522.93 / $10,248.62
| Professional | | $5,233.34 | $7,522.93 | $10,248.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,726.58 / $5,076.80 / $6,370.65
| Professional | | $4,726.58 | $5,076.80 | $6,370.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,451.66 / $7,860.06 / $7,860.06
| Facility | | $5,451.66 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.99 / $7,860.06 / $7,860.06
| Professional | | $935.99 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $469.76 / $4,697.60 / $8,377.54
| Facility | | $469.76 | $4,697.60 | $8,377.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,970.07 / $4,060.50 / $8,156.93
| Professional | | $2,970.07 | $4,060.50 | $8,156.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,907.41 / $3,861.08 / $7,651.68
| Professional | | $2,907.41 | $3,861.08 | $7,651.68 |