- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.36 / $1,992.16 / $2,490.19
| Professional | | $1,810.36 | $1,992.16 | $2,490.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,578.00 / $3,775.00 / $13,851.75
| Facility | | $1,578.00 | $3,775.00 | $13,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.04 / $4,727.72 / $4,727.72
| Professional | | $1,429.04 | $4,727.72 | $4,727.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.15 / $1,578.00 / $1,783.23
| Facility | | $1,066.15 | $1,578.00 | $1,783.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.15 / $1,582.35 / $2,090.42
| Professional | | $1,066.15 | $1,582.35 | $2,090.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,525.00 / $2,356.80
| Professional | | $7.00 | $1,525.00 | $2,356.80 |