- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,385.70 / $4,483.80 / $5,482.13
| Professional | | $4,385.70 | $4,483.80 | $5,482.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.54 / $596.36 / $6,541.33
| Facility | | $484.54 | $596.36 | $6,541.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.54 / $521.82 / $7,044.51
| Professional | | $484.54 | $521.82 | $7,044.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $7,602.76
| Facility | | $5,470.13 | $5,470.13 | $7,602.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $5,470.13
| Professional | | $585.88 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.43 / $3,613.45 / $6,185.70
| Professional | | $2,652.43 | $3,613.45 | $6,185.70 |