- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,015.16 / $5,899.73 / $6,268.95
| Professional | | $5,015.16 | $5,899.73 | $6,268.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.47 / $763.66 / $8,376.36
| Facility | | $620.47 | $763.66 | $8,376.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.47 / $668.20 / $9,020.69
| Professional | | $620.47 | $668.20 | $9,020.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,969.00 / $3,969.00 / $6,408.42
| Facility | | $3,969.00 | $3,969.00 | $6,408.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.65 / $3,373.65 / $3,969.00
| Professional | | $674.65 | $3,373.65 | $3,969.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.91 / $635.21 / $4,234.72
| Facility | | $534.91 | $635.21 | $4,234.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.75 / $3,174.84 / $5,284.40
| Professional | | $2,235.75 | $3,174.84 | $5,284.40 |