- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.08 / $1,883.93 / $2,237.55
| Professional | | $1,756.08 | $1,883.93 | $2,237.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.58 / $250.56 / $2,712.70
| Facility | | $203.58 | $250.56 | $2,712.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $219.24 / $2,921.37
| Professional | | $203.58 | $219.24 | $2,921.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $3,501.12
| Facility | | $2,225.09 | $2,225.09 | $3,501.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $2,225.09
| Professional | | $246.17 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,289.11 / $2,228.30
| Professional | | $1,020.64 | $1,289.11 | $2,228.30 |