- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.36 / $2,463.51 / $3,079.39
| Professional | | $2,323.36 | $2,463.51 | $3,079.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.58 / $1,927.79 / $2,990.71
| Facility | | $860.58 | $1,927.79 | $2,990.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,178.67 / $5,178.67 / $5,178.67
| Professional | | $5,178.67 | $5,178.67 | $5,178.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,864.00 / $1,864.00 / $1,864.00
| Facility | | $1,864.00 | $1,864.00 | $1,864.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.00 / $1,932.00 / $2,305.77
| Professional | | $1,706.00 | $1,932.00 | $2,305.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.83 / $1,894.93 / $1,926.61
| Professional | | $1,327.83 | $1,894.93 | $1,926.61 |