- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.46 / $2,193.75 / $2,815.28
| Professional | | $2,159.46 | $2,193.75 | $2,815.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.07 / $291.77 / $2,712.70
| Facility | | $237.07 | $291.77 | $2,712.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.07 / $255.30 / $2,921.37
| Professional | | $237.07 | $255.30 | $2,921.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $4,264.28
| Facility | | $2,671.66 | $2,671.66 | $4,264.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $2,671.66
| Professional | | $286.64 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.64 / $1,960.98 / $3,449.10
| Professional | | $1,419.64 | $1,960.98 | $3,449.10 |