- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.67 / $2,802.42 / $3,503.03
| Professional | | $2,546.67 | $2,802.42 | $3,503.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,103.00 / $2,968.79 / $22,807.05
| Facility | | $2,103.00 | $2,968.79 | $22,807.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.21 / $6,308.29 / $6,308.29
| Professional | | $2,026.21 | $6,308.29 | $6,308.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.66 / $2,103.00 / $2,528.41
| Facility | | $1,517.66 | $2,103.00 | $2,528.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.66 / $2,234.42 / $2,968.79
| Professional | | $1,517.66 | $2,234.42 | $2,968.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $2,148.19 / $3,313.60
| Professional | | $7.00 | $2,148.19 | $3,313.60 |