- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,201.36 / $5,491.02 / $6,863.78
| Professional | | $3,201.36 | $5,491.02 | $6,863.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $6,797.73
| Facility | | $3,818.66 | $3,818.66 | $6,797.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.67 / $3,818.66 / $12,116.25
| Professional | | $738.67 | $3,818.66 | $12,116.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.60 / $5,765.57 / $7,206.97
| Facility | | $578.60 | $5,765.57 | $7,206.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.90 / $3,338.17 / $5,186.39
| Professional | | $2,002.90 | $3,338.17 | $5,186.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,462.23 / $3,321.12 / $5,186.39
| Professional | | $2,462.23 | $3,321.12 | $5,186.39 |