- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,760.83 / $8,317.64
| Professional | | $3,890.45 | $6,760.83 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $8,511.38
| Facility | | $5,128.61 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,128.61 / $14,791.08
| Professional | | $912.01 | $5,128.61 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $7,079.46 / $8,912.51
| Facility | | $707.95 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,073.80 / $6,918.31
| Professional | | $2,398.83 | $4,073.80 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,318.26 / $5,754.40
| Facility | | $501.19 | $1,318.26 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,073.80 / $6,918.31
| Professional | | $3,019.95 | $4,073.80 | $6,918.31 |