- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,330.78 / $3,375.53 / $4,163.47
| Professional | | $3,330.78 | $3,375.53 | $4,163.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.77 / $448.95 / $4,924.45
| Facility | | $364.77 | $448.95 | $4,924.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.77 / $392.83 / $5,303.25
| Professional | | $364.77 | $392.83 | $5,303.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $5,872.68
| Facility | | $4,124.25 | $4,124.25 | $5,872.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.07 / $4,124.25 / $4,124.25
| Professional | | $441.07 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.86 / $2,732.15 / $4,759.00
| Professional | | $2,048.86 | $2,732.15 | $4,759.00 |