- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.04 / $1,854.26 / $2,317.82
| Professional | | $1,685.04 | $1,854.26 | $2,317.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.37 / $1,799.67 / $2,387.52
| Facility | | $833.37 | $1,799.67 | $2,387.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,352.35 / $5,352.35 / $5,352.35
| Professional | | $5,352.35 | $5,352.35 | $5,352.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.42 / $1,662.00 / $1,662.00
| Facility | | $1,348.42 | $1,662.00 | $1,662.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.42 / $1,664.00 / $1,805.83
| Professional | | $1,348.42 | $1,664.00 | $1,805.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.57 / $1,532.89 / $1,558.52
| Professional | | $1,133.57 | $1,532.89 | $1,558.52 |