- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,660.16 / $3,277.73 / $3,501.75
| Professional | | $2,660.16 | $3,277.73 | $3,501.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.84 / $346.59 / $426.58
| Facility | | $328.84 | $346.59 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.59 / $354.14 / $479.90
| Professional | | $346.59 | $354.14 | $479.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $5,625.11
| Facility | | $3,655.97 | $3,655.97 | $5,625.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $23,523.72
| Professional | | $408.57 | $3,655.97 | $23,523.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.40 / $2,188.73 / $4,472.89
| Professional | | $1,773.40 | $2,188.73 | $4,472.89 |