- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,994.03 / $9,129.58 / $9,129.58
| Professional | | $1,994.03 | $9,129.58 | $9,129.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.01 / $2,782.01 / $2,782.01
| Facility | | $2,782.01 | $2,782.01 | $2,782.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.75 / $2,782.01 / $2,782.01
| Professional | | $2,022.75 | $2,782.01 | $2,782.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.01 / $3,251.30 / $3,331.38
| Facility | | $2,782.01 | $3,251.30 | $3,331.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.93 / $2,411.12 / $3,682.70
| Professional | | $1,701.93 | $2,411.12 | $3,682.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.02 / $3,107.40 / $4,871.04
| Professional | | $2,551.02 | $3,107.40 | $4,871.04 |