- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,941.62 / $2,965.73 / $3,677.03
| Professional | | $2,941.62 | $2,965.73 | $3,677.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.49 / $394.45 / $4,326.60
| Facility | | $320.49 | $394.45 | $4,326.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.49 / $345.14 / $4,659.42
| Professional | | $320.49 | $345.14 | $4,659.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $5,237.12
| Facility | | $3,626.76 | $3,626.76 | $5,237.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,626.76 / $3,626.76
| Professional | | $387.52 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.15 / $2,422.69 / $4,551.50
| Professional | | $1,827.15 | $2,422.69 | $4,551.50 |