- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.43 / $6,786.30 / $6,786.30
| Professional | | $1,658.43 | $6,786.30 | $6,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,108.46 / $2,108.46 / $2,108.46
| Facility | | $2,108.46 | $2,108.46 | $2,108.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.13 / $1,242.02 / $2,108.46
| Professional | | $1,231.13 | $1,242.02 | $2,108.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.00 / $1,488.33 / $2,287.13
| Facility | | $1,120.00 | $1,488.33 | $2,287.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.40 / $1,823.58 / $2,515.19
| Professional | | $1,270.40 | $1,823.58 | $2,515.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.00 / $1,490.00 / $1,490.00
| Facility | | $1,490.00 | $1,490.00 | $1,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.71 / $2,096.69 / $2,422.05
| Professional | | $1,805.71 | $2,096.69 | $2,422.05 |