- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.52 / $2,048.69 / $2,654.03
| Professional | | $2,039.52 | $2,048.69 | $2,654.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.40 / $272.49 / $2,668.92
| Facility | | $221.40 | $272.49 | $2,668.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.40 / $238.43 / $2,874.22
| Professional | | $221.40 | $238.43 | $2,874.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $4,083.65
| Facility | | $2,254.90 | $2,254.90 | $4,083.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.70 / $2,254.90 / $2,387.82
| Professional | | $267.70 | $2,254.90 | $2,387.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.40 / $1,855.56 / $3,292.10
| Professional | | $1,338.40 | $1,855.56 | $3,292.10 |