- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.46 / $3,174.18 / $3,967.73
| Professional | | $2,679.46 | $3,174.18 | $3,967.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $3,991.83
| Facility | | $2,187.00 | $2,187.00 | $3,991.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.04 / $2,187.00 / $6,363.75
| Professional | | $418.04 | $2,187.00 | $6,363.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.30 / $3,332.89 / $5,872.68
| Facility | | $329.30 | $3,332.89 | $5,872.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.74 / $2,741.85 / $4,759.00
| Professional | | $1,555.74 | $2,741.85 | $4,759.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.74 / $2,741.85 / $4,759.00
| Professional | | $1,555.74 | $2,741.85 | $4,759.00 |