- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,491.02 / $6,459.53 / $6,863.78
| Professional | | $5,491.02 | $6,459.53 | $6,863.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.35 / $836.12 / $9,171.19
| Facility | | $679.35 | $836.12 | $9,171.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.35 / $731.61 / $9,876.67
| Professional | | $679.35 | $731.61 | $9,876.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $7,016.64
| Facility | | $3,818.66 | $3,818.66 | $7,016.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.67 / $3,818.66 / $3,818.66
| Professional | | $738.67 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.54 / $3,476.08 / $5,236.30
| Professional | | $2,670.54 | $3,476.08 | $5,236.30 |