- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.38 / $1,427.48 / $1,516.73
| Professional | | $1,213.38 | $1,427.48 | $1,516.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.12 / $184.76 / $2,026.59
| Facility | | $150.12 | $184.76 | $2,026.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.12 / $161.66 / $2,182.48
| Professional | | $150.12 | $161.66 | $2,182.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.39 / $1,071.00 / $2,325.84
| Facility | | $171.39 | $1,071.00 | $2,325.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $1,071.00 / $1,318.54
| Professional | | $163.22 | $1,071.00 | $1,318.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.44 / $979.52 / $1,653.05
| Professional | | $811.44 | $979.52 | $1,653.05 |