- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.94 / $1,741.81 / $7,283.00
| Professional | | $1,418.94 | $1,741.81 | $7,283.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,163.67 / $2,163.67 / $2,163.67
| Facility | | $2,163.67 | $2,163.67 | $2,163.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.88 / $2,163.67 / $2,319.85
| Professional | | $1,582.88 | $2,163.67 | $2,319.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.32 / $2,592.85 / $2,656.50
| Facility | | $1,069.32 | $2,592.85 | $2,656.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.26 / $1,961.10 / $2,828.70
| Professional | | $1,307.26 | $1,961.10 | $2,828.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.39 / $2,359.98 / $3,763.82
| Professional | | $2,034.39 | $2,359.98 | $3,763.82 |