- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.01 / $2,545.87 / $2,995.14
| Professional | | $2,456.01 | $2,545.87 | $2,995.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.58 / $385.70 / $1,099.48
| Facility | | $308.58 | $385.70 | $1,099.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,545.86 / $2,545.86
| Professional | | $2,495.94 | $2,545.86 | $2,545.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.01 / $2,545.87 / $2,545.87
| Professional | | $2,456.01 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.56 / $2,495.94 / $3,619.13
| Professional | | $2,121.56 | $2,495.94 | $3,619.13 |