- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $3,715.35
| Professional | | $2,630.27 | $2,951.21 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $323.59 / $4,365.16
| Facility | | $323.59 | $323.59 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $4,677.35
| Professional | | $346.74 | $346.74 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,630.78 / $5,248.07
| Facility | | $794.33 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,630.78 / $3,630.78
| Professional | | $389.05 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $3,311.31
| Facility | | $316.23 | $371.54 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $3,890.45
| Professional | | $1,862.09 | $2,398.83 | $3,890.45 |