- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.86 / $2,050.73 / $2,637.83
| Professional | | $2,026.86 | $2,050.73 | $2,637.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.60 / $272.74 / $2,715.69
| Facility | | $221.60 | $272.74 | $2,715.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.60 / $238.65 / $2,924.59
| Professional | | $221.60 | $238.65 | $2,924.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.95 / $2,592.00 / $2,592.00
| Professional | | $267.95 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.20 / $1,836.01 / $3,157.60
| Professional | | $1,330.20 | $1,836.01 | $3,157.60 |