- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,515.14 / $3,817.70 / $4,187.26
| Professional | | $2,515.14 | $3,817.70 | $4,187.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $599.00 / $8,869.69 / $12,604.29
| Facility | | $599.00 | $8,869.69 | $12,604.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.14 / $1,893.14 / $6,665.76
| Professional | | $1,893.14 | $1,893.14 | $6,665.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,662.40 / $4,653.41 / $6,156.94
| Professional | | $3,662.40 | $4,653.41 | $6,156.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,343.63 / $4,097.05 / $9,092.20
| Professional | | $3,343.63 | $4,097.05 | $9,092.20 |