- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.73 / $1,806.73 / $2,258.42
| Professional | | $1,806.73 | $1,806.73 | $2,258.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.00 / $5,448.50 / $26,542.00
| Facility | | $1,444.00 | $5,448.50 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.00 / $1,694.34 / $7,587.00
| Professional | | $1,286.00 | $1,694.34 | $7,587.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $982.89 / $1,273.82 / $1,444.00
| Facility | | $982.89 | $1,273.82 | $1,444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.26 / $1,322.00 / $1,744.64
| Professional | | $948.26 | $1,322.00 | $1,744.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $1,603.90 / $1,932.70
| Professional | | $5.00 | $1,603.90 | $1,932.70 |