- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.49 / $2,259.17 / $2,823.98
| Professional | | $1,945.49 | $2,259.17 | $2,823.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $4,515.00
| Professional | | $286.64 | $2,671.66 | $4,515.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.11 / $2,391.12 / $4,264.28
| Facility | | $239.11 | $2,391.12 | $4,264.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.44 / $1,960.98 / $3,449.10
| Professional | | $1,134.44 | $1,960.98 | $3,449.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.44 / $1,909.38 / $3,449.10
| Professional | | $1,134.44 | $1,909.38 | $3,449.10 |