- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,391.72 / $6,342.68 / $6,739.65
| Professional | | $5,391.72 | $6,342.68 | $6,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $667.06 / $821.00 / $9,005.35
| Facility | | $667.06 | $821.00 | $9,005.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.06 / $718.38 / $9,698.07
| Professional | | $667.06 | $718.38 | $9,698.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,488.00 / $4,978.93 / $6,889.88
| Facility | | $4,488.00 | $4,978.93 | $6,889.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.31 / $4,232.09 / $4,978.93
| Professional | | $725.31 | $4,232.09 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,848.27 / $6,848.27 / $6,848.27
| Professional | | $6,848.27 | $6,848.27 | $6,848.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.71 / $3,413.20 / $5,688.67
| Professional | | $2,403.71 | $3,413.20 | $5,688.67 |