- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.56 / $1,604.10 / $1,704.45
| Professional | | $1,363.56 | $1,604.10 | $1,704.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.69 / $207.62 / $2,277.38
| Facility | | $168.69 | $207.62 | $2,277.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.69 / $181.67 / $2,452.56
| Professional | | $168.69 | $181.67 | $2,452.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $2,613.40
| Facility | | $192.60 | $1,436.52 | $2,613.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,436.52 / $10,257.35
| Professional | | $183.43 | $1,436.52 | $10,257.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.77 / $1,221.82 / $1,857.43
| Professional | | $911.77 | $1,221.82 | $1,857.43 |