- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.26 / $1,926.83 / $2,320.94
| Professional | | $1,813.26 | $1,926.83 | $2,320.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.22 / $256.27 / $2,466.21
| Facility | | $208.22 | $256.27 | $2,466.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.22 / $224.24 / $2,655.93
| Professional | | $208.22 | $224.24 | $2,655.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,387.48 / $2,387.48
| Professional | | $251.77 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.09 / $1,505.76 / $2,509.60
| Professional | | $1,090.09 | $1,505.76 | $2,509.60 |