- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $1,174.90 / $1,288.25
| Professional | | $223.87 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,737.80 / $1,905.46
| Professional | | $1,621.81 | $1,737.80 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,290.87
| Facility | | $2,187.76 | $2,187.76 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,290.87
| Professional | | $2,187.76 | $2,187.76 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $2,454.71
| Facility | | $812.83 | $1,412.54 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,737.80 / $1,905.46
| Professional | | $1,621.81 | $1,737.80 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $2,238.72
| Professional | | $1,348.96 | $1,949.84 | $2,238.72 |