- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,623.41 / $7,943.28
| Professional | | $4,786.30 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $7,585.78 / $7,585.78
| Professional | | $812.83 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $9,549.93 / $32,359.37
| Professional | | $2,454.71 | $9,549.93 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $741.31 / $3,801.89
| Facility | | $245.47 | $741.31 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,548.13 / $9,549.93
| Professional | | $2,398.83 | $3,548.13 | $9,549.93 |