- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,729.63 / $2,762.70 / $3,453.38
| Professional | | $2,729.63 | $2,762.70 | $3,453.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.98 / $363.05 / $3,982.19
| Facility | | $294.98 | $363.05 | $3,982.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.98 / $317.67 / $4,288.51
| Professional | | $294.98 | $317.67 | $4,288.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $5,102.45
| Facility | | $3,349.85 | $3,349.85 | $5,102.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.67 / $3,349.85 / $3,349.85
| Professional | | $356.67 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.32 / $2,207.52 / $4,124.00
| Professional | | $1,741.32 | $2,207.52 | $4,124.00 |