- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,027.18 / $3,491.93 / $3,783.98
| Professional | | $3,027.18 | $3,491.93 | $3,783.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $377.35 / $381.12 / $4,427.25
| Facility | | $377.35 | $381.12 | $4,427.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.35 / $410.44 / $4,767.81
| Professional | | $377.35 | $410.44 | $4,767.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $6,417.35
| Facility | | $3,282.89 | $3,282.89 | $6,417.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $26,836.80
| Professional | | $456.28 | $3,282.89 | $26,836.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.10 / $3,320.66 / $4,869.05
| Professional | | $2,390.10 | $3,320.66 | $4,869.05 |