- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.93 / $1,039.10 / $1,295.73
| Professional | | $1,036.93 | $1,039.10 | $1,295.73 |
- 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
- $1,987.00 / $2,384.00 / $3,607.00
| Professional | | $1,987.00 | $2,384.00 | $3,607.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.62 / $2,078.21 / $2,868.11
| Professional | | $1,438.62 | $2,078.21 | $2,868.11 |
- 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
- $1,207.94 / $2,094.46 / $3,315.00
| Professional | | $1,207.94 | $2,094.46 | $3,315.00 |