- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,110.82 / $3,600.15 / $3,888.53
| Professional | | $3,110.82 | $3,600.15 | $3,888.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.87 / $387.89 / $4,549.58
| Facility | | $387.87 | $387.89 | $4,549.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.87 / $417.73 / $4,899.55
| Professional | | $387.87 | $417.73 | $4,899.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $6,616.43
| Facility | | $1,642.21 | $1,642.21 | $6,616.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $4,198.50
| Professional | | $470.42 | $1,642.21 | $4,198.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,733.14 / $3,733.14 / $3,733.14
| Professional | | $3,733.14 | $3,733.14 | $3,733.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.44 / $3,401.16 / $4,955.32
| Professional | | $2,432.44 | $3,401.16 | $4,955.32 |