- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.60 / $2,901.55 / $5,186.16
| Professional | | $2,217.60 | $2,901.55 | $5,186.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $2,187.00
| Facility | | $2,187.00 | $2,187.00 | $2,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.95 / $2,187.00 / $6,363.75
| Professional | | $1,858.95 | $2,187.00 | $6,363.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.43 / $394.43 / $3,788.32
| Professional | | $394.43 | $394.43 | $3,788.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.16 / $2,182.36 / $4,363.66
| Professional | | $1,894.16 | $2,182.36 | $4,363.66 |