- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,726.18 / $4,318.05 / $4,695.60
| Professional | | $3,726.18 | $4,318.05 | $4,695.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $464.75 / $516.52 / $635.07
| Facility | | $464.75 | $516.52 | $635.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.75 / $516.00 / $714.46
| Professional | | $464.75 | $516.00 | $714.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $6,993.73
| Facility | | $5,106.14 | $5,106.14 | $6,993.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $29,247.18
| Professional | | $560.27 | $5,106.14 | $29,247.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.04 / $2,860.00 / $5,687.50
| Professional | | $2,378.04 | $2,860.00 | $5,687.50 |