- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.19 / $2,438.57 / $2,533.58
| Professional | | $2,128.19 | $2,438.57 | $2,533.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.08 / $2,203.19 / $2,592.00
| Professional | | $296.08 | $2,203.19 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,737.87 / $3,737.87 / $3,737.87
| Professional | | $3,737.87 | $3,737.87 | $3,737.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.81 / $1,277.72 / $2,993.50
| Professional | | $851.81 | $1,277.72 | $2,993.50 |