- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,918.82 / $6,721.50 / $8,401.87
| Professional | | $3,918.82 | $6,721.50 | $8,401.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $8,321.02
| Facility | | $5,109.46 | $5,109.46 | $8,321.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.20 / $4,343.04 / $18,539.06
| Professional | | $904.20 | $4,343.04 | $18,539.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.26 / $7,057.58 / $8,821.96
| Facility | | $708.26 | $7,057.58 | $8,821.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.73 / $4,086.23 / $6,971.00
| Professional | | $2,451.73 | $4,086.23 | $6,971.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.00 / $4,077.44 / $6,971.00
| Professional | | $3,014.00 | $4,077.44 | $6,971.00 |