- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,569.90 / $1,846.73 / $1,962.38
| Professional | | $1,569.90 | $1,846.73 | $1,962.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.22 / $239.04 / $2,621.97
| Facility | | $194.22 | $239.04 | $2,621.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.22 / $209.16 / $2,823.66
| Professional | | $194.22 | $209.16 | $2,823.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $3,008.74
| Facility | | $1,219.64 | $1,219.64 | $3,008.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.18 / $1,219.64 / $2,166.21
| Professional | | $211.18 | $1,219.64 | $2,166.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.69 / $1,406.79 / $2,138.41
| Professional | | $1,049.69 | $1,406.79 | $2,138.41 |