- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,497.71 / $11,358.30 / $11,358.30
| Professional | | $2,497.71 | $11,358.30 | $11,358.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,472.91 / $3,472.91 / $3,472.91
| Facility | | $3,472.91 | $3,472.91 | $3,472.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.28 / $3,472.91 / $3,472.91
| Professional | | $1,461.28 | $3,472.91 | $3,472.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,366.00 / $2,507.23 / $3,472.91
| Facility | | $2,366.00 | $2,507.23 | $3,472.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.17 / $3,017.45 / $4,608.80
| Professional | | $1,958.17 | $3,017.45 | $4,608.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,329.59 / $3,739.84 / $6,083.71
| Professional | | $2,329.59 | $3,739.84 | $6,083.71 |