- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.06 / $1,857.07 / $2,042.77
| Professional | | $1,857.06 | $1,857.07 | $2,042.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $696.62 / $874.43 / $2,281.27
| Facility | | $696.62 | $874.43 | $2,281.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $1,857.07
| Professional | | $1,857.07 | $1,857.07 | $1,857.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Facility | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.66 / $2,033.61 / $3,119.67
| Professional | | $1,757.66 | $2,033.61 | $3,119.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.57 / $1,857.06 / $2,042.77
| Professional | | $1,346.57 | $1,857.06 | $2,042.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.66 / $1,875.28 / $2,812.92
| Professional | | $1,757.66 | $1,875.28 | $2,812.92 |