- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.02 / $2,096.33 / $7,870.54
| Professional | | $1,602.02 | $2,096.33 | $7,870.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,379.25 / $2,379.25 / $2,379.25
| Facility | | $2,379.25 | $2,379.25 | $2,379.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.17 / $2,379.25 / $2,553.23
| Professional | | $966.17 | $2,379.25 | $2,553.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.78 / $1,273.58 / $2,379.25
| Facility | | $1,002.78 | $1,273.58 | $2,379.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.97 / $2,379.25 / $3,117.80
| Professional | | $1,375.97 | $2,379.25 | $3,117.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.95 / $2,444.39 / $2,831.39
| Professional | | $1,912.95 | $2,444.39 | $2,831.39 |