- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.10 / $1,974.14 / $2,074.29
| Professional | | $1,528.10 | $1,974.14 | $2,074.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,944.82 / $6,678.63 / $7,906.72
| Facility | | $4,944.82 | $6,678.63 | $7,906.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.69 / $2,284.34 / $3,162.75
| Professional | | $1,941.69 | $2,284.34 | $3,162.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,022.95 / $2,400.00 / $2,400.00
| Facility | | $2,022.95 | $2,400.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.00 / $2,400.00 / $2,400.00
| Professional | | $1,752.00 | $2,400.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.99 / $2,186.41 / $2,908.02
| Professional | | $1,576.99 | $2,186.41 | $2,908.02 |