- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $2,570.40
| Professional | | $1,862.09 | $2,089.30 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,548.82 / $3,467.37
| Facility | | $54.95 | $1,548.82 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $7,585.78
| Professional | | $1,412.54 | $2,344.23 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,659.59
| Professional | | $1,548.82 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $1,905.46
| Professional | | $1,584.89 | $1,819.70 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $1,819.70 / $2,187.76
| Professional | | $7.08 | $1,819.70 | $2,187.76 |