- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,918.31 / $8,317.64
| Professional | | $4,786.30 | $6,918.31 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $11,220.18
| Facility | | $831.76 | $831.76 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $12,022.64
| Professional | | $891.25 | $891.25 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,128.61 / $8,511.38
| Facility | | $1,288.25 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,128.61 / $6,165.95
| Professional | | $912.01 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $5,623.41
| Facility | | $724.44 | $851.14 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,265.80 / $6,918.31
| Professional | | $3,235.94 | $4,265.80 | $6,918.31 |