- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.78 / $1,802.10 / $2,252.63
| Professional | | $1,334.78 | $1,802.10 | $2,252.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $3,768.75
| Professional | | $246.17 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.04 / $1,892.21 / $16,659.23
| Facility | | $164.04 | $1,892.21 | $16,659.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.07 / $1,384.72 / $2,228.30
| Professional | | $835.07 | $1,384.72 | $2,228.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.71 / $1,273.76 / $2,228.30
| Professional | | $737.71 | $1,273.76 | $2,228.30 |