- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,025.60 / $8,511.38
| Professional | | $4,466.84 | $6,025.60 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $8,128.31
| Professional | | $5,248.07 | $5,248.07 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $6,606.93
| Facility | | $5,128.61 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $6,606.93 / $12,302.69
| Professional | | $758.58 | $6,606.93 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,244.36 / $7,244.36
| Professional | | $7,079.46 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $4,466.84
| Facility | | $489.78 | $707.95 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $4,570.88
| Professional | | $2,691.53 | $3,019.95 | $4,570.88 |