- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.42 / $1,913.33 / $2,033.03
| Professional | | $1,626.42 | $1,913.33 | $2,033.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.22 / $247.66 / $2,716.48
| Facility | | $201.22 | $247.66 | $2,716.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.22 / $216.70 / $2,925.44
| Professional | | $201.22 | $216.70 | $2,925.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $3,117.54
| Facility | | $1,406.76 | $1,406.76 | $3,117.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $12,235.81
| Professional | | $218.80 | $1,406.76 | $12,235.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.65 / $1,186.52 / $2,215.73
| Professional | | $1,087.65 | $1,186.52 | $2,215.73 |