- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.88 / $2,239.88 / $2,799.84
| Professional | | $2,239.88 | $2,239.88 | $2,799.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,363.16 / $1,694.03 / $21,809.29
| Facility | | $1,363.16 | $1,694.03 | $21,809.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,853.13 / $5,504.72 / $5,504.72
| Professional | | $2,853.13 | $5,504.72 | $5,504.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.68 / $18,454.00 / $23,486.93
| Facility | | $1,388.68 | $18,454.00 | $23,486.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.16 / $1,388.68 / $2,853.13
| Professional | | $1,363.16 | $1,388.68 | $2,853.13 |