- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.96 / $247.46 / $1,301.09
| Professional | | $224.96 | $247.46 | $1,301.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,927.06 / $1,927.06 / $1,927.06
| Facility | | $1,927.06 | $1,927.06 | $1,927.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.00 / $1,734.35 / $1,927.06
| Professional | | $1,638.00 | $1,734.35 | $1,927.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $815.06 / $820.34 / $1,927.06
| Facility | | $815.06 | $820.34 | $1,927.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.00 / $1,927.06 / $2,502.00
| Professional | | $1,638.00 | $1,927.06 | $2,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.00 / $1,962.14 / $2,165.12
| Professional | | $1,590.00 | $1,962.14 | $2,165.12 |