- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,823.10 / $5,495.71 / $7,174.60
| Professional | | $3,823.10 | $5,495.71 | $7,174.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,385.77 / $4,388.00 / $5,781.54
| Professional | | $4,385.77 | $4,388.00 | $5,781.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,899.36 / $5,470.13 / $5,470.13
| Facility | | $3,899.36 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.96 / $5,470.13 / $5,470.13
| Professional | | $651.96 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,748.52 / $4,969.67 / $7,977.42
| Facility | | $3,748.52 | $4,969.67 | $7,977.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,466.80 / $3,482.52 / $6,303.03
| Professional | | $2,466.80 | $3,482.52 | $6,303.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.30 / $2,994.21 / $6,303.03
| Professional | | $2,349.30 | $2,994.21 | $6,303.03 |