- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,817.24 / $6,843.30 / $7,271.55
| Professional | | $5,817.24 | $6,843.30 | $7,271.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.71 / $885.79 / $9,716.03
| Facility | | $719.71 | $885.79 | $9,716.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.71 / $775.07 / $10,463.42
| Professional | | $719.71 | $775.07 | $10,463.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $7,433.65
| Facility | | $3,704.40 | $3,704.40 | $7,433.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $5,351.58
| Professional | | $782.55 | $3,704.40 | $5,351.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,593.46 / $3,682.60 / $6,129.80
| Professional | | $2,593.46 | $3,682.60 | $6,129.80 |