- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.04 / $1,974.38 / $2,511.08
| Professional | | $1,949.04 | $1,974.38 | $2,511.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.36 / $262.60 / $2,712.70
| Facility | | $213.36 | $262.60 | $2,712.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.36 / $229.78 / $2,921.37
| Professional | | $213.36 | $229.78 | $2,921.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $3,744.63
| Facility | | $2,416.31 | $2,416.31 | $3,744.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.99 / $2,416.31 / $2,416.31
| Professional | | $257.99 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.20 / $1,684.56 / $2,807.60
| Professional | | $1,266.20 | $1,684.56 | $2,807.60 |