- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,348.44 / $2,584.27 / $3,230.34
| Professional | | $2,348.44 | $2,584.27 | $3,230.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,793.94 / $2,456.54 / $3,331.23
| Facility | | $1,793.94 | $2,456.54 | $3,331.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,345.00 / $8,345.00 / $8,345.00
| Professional | | $8,345.00 | $8,345.00 | $8,345.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,881.71 / $2,256.00 / $2,256.00
| Facility | | $1,881.71 | $2,256.00 | $2,256.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.71 / $2,257.00 / $2,520.19
| Professional | | $1,881.71 | $2,257.00 | $2,520.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.01 / $2,138.62 / $2,174.37
| Professional | | $1,564.01 | $2,138.62 | $2,174.37 |