- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.66 / $2,991.83 / $3,702.08
| Professional | | $2,961.66 | $2,991.83 | $3,702.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.31 / $397.92 / $4,364.68
| Facility | | $323.31 | $397.92 | $4,364.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.31 / $348.18 / $4,700.43
| Professional | | $323.31 | $348.18 | $4,700.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $5,253.74
| Facility | | $3,657.49 | $3,657.49 | $5,253.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.93 / $3,657.49 / $3,657.49
| Professional | | $390.93 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.56 / $2,326.23 / $4,332.30
| Professional | | $1,866.56 | $2,326.23 | $4,332.30 |