- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,833.26 / $2,896.88 / $3,655.43
| Professional | | $2,833.26 | $2,896.88 | $3,655.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.05 / $385.29 / $3,634.87
| Facility | | $313.05 | $385.29 | $3,634.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.05 / $337.13 / $3,914.48
| Professional | | $313.05 | $337.13 | $3,914.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $5,376.08
| Facility | | $2,673.00 | $2,673.00 | $5,376.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.53 / $2,673.00 / $3,214.80
| Professional | | $378.53 | $2,673.00 | $3,214.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.16 / $2,465.87 / $4,433.20
| Professional | | $1,843.16 | $2,465.87 | $4,433.20 |