- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.48 / $9,152.59 / $9,152.59
| Professional | | $2,016.48 | $9,152.59 | $9,152.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,786.74 / $2,786.74 / $2,786.74
| Facility | | $2,786.74 | $2,786.74 | $2,786.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,105.14 / $2,786.74 / $3,064.81
| Professional | | $2,105.14 | $2,786.74 | $3,064.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,371.47 / $3,302.00 / $3,435.74
| Facility | | $1,371.47 | $3,302.00 | $3,435.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.85 / $2,557.53 / $3,689.00
| Professional | | $1,704.85 | $2,557.53 | $3,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,590.80 / $3,114.60 / $4,881.22
| Professional | | $2,590.80 | $3,114.60 | $4,881.22 |