- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.00 / $2,277.06 / $2,959.80
| Professional | | $2,196.00 | $2,277.06 | $2,959.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.31 / $292.07 / $2,548.35
| Facility | | $237.31 | $292.07 | $2,548.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.31 / $255.56 / $2,744.38
| Professional | | $237.31 | $255.56 | $2,744.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $4,847.72
| Facility | | $2,446.40 | $2,446.40 | $4,847.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $2,792.28
| Professional | | $286.94 | $2,446.40 | $2,792.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.88 / $2,127.44 / $3,997.50
| Professional | | $1,492.88 | $2,127.44 | $3,997.50 |