- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $1,905.46
| Professional | | $912.01 | $1,122.02 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $2,398.83
| Facility | | $1,202.26 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,905.46
| Professional | | $891.25 | $891.25 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,288.25 / $1,737.80
| Facility | | $724.44 | $1,288.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $954.99 / $1,479.11
| Professional | | $870.96 | $954.99 | $1,479.11 |