- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.82 / $2,043.15 / $2,171.03
| Professional | | $1,736.82 | $2,043.15 | $2,171.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.88 / $2,322.65 / $2,900.84
| Facility | | $214.88 | $2,322.65 | $2,900.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.88 / $2,322.65 / $3,215.98
| Professional | | $214.88 | $2,322.65 | $3,215.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $3,329.08
| Facility | | $1,440.00 | $1,440.00 | $3,329.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.64 / $1,440.00 / $2,396.69
| Professional | | $233.64 | $1,440.00 | $2,396.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.04 / $2,260.04 / $2,260.04
| Professional | | $2,260.04 | $2,260.04 | $2,260.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.45 / $1,556.42 / $2,366.09
| Professional | | $1,161.45 | $1,556.42 | $2,366.09 |