- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,748.12 / $3,177.00 / $3,435.15
| Professional | | $2,748.12 | $3,177.00 | $3,435.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.32 / $343.74 / $4,019.13
| Facility | | $343.32 | $343.74 | $4,019.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.32 / $370.18 / $4,328.29
| Professional | | $343.32 | $370.18 | $4,328.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $5,838.74
| Facility | | $3,248.38 | $3,248.38 | $5,838.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $24,417.11
| Professional | | $415.13 | $3,248.38 | $24,417.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.58 / $2,936.49 / $4,391.30
| Professional | | $2,155.58 | $2,936.49 | $4,391.30 |