- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.67 / $1,016.40 / $1,269.56
| Professional | | $1,002.67 | $1,016.40 | $1,269.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.00 / $2,322.00 / $3,512.00
| Professional | | $1,935.00 | $2,322.00 | $3,512.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.07 / $2,032.80 / $2,792.70
| Professional | | $1,385.07 | $2,032.80 | $2,792.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.04 / $2,026.69 / $3,680.29
| Professional | | $1,341.04 | $2,026.69 | $3,680.29 |