- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.38 / $2,171.73 / $2,513.53
| Professional | | $1,657.38 | $2,171.73 | $2,513.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $507.00 / $641.21
| Facility | | $507.00 | $507.00 | $641.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,333.41 / $2,824.66 / $3,509.87
| Professional | | $2,333.41 | $2,824.66 | $3,509.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.00 / $173.00 / $471.00
| Facility | | $173.00 | $173.00 | $471.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.36 / $2,749.56 / $5,264.11
| Professional | | $1,912.36 | $2,749.56 | $5,264.11 |