- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,474.42 / $3,093.03 / $5,179.85
| Professional | | $2,474.42 | $3,093.03 | $5,179.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.86 / $1,671.74 / $2,659.67
| Facility | | $1,208.86 | $1,671.74 | $2,659.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.00 / $5,494.34 / $5,494.34
| Professional | | $1,853.00 | $5,494.34 | $5,494.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,853.00 / $1,853.00 / $1,853.00
| Facility | | $1,853.00 | $1,853.00 | $1,853.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.00 / $1,853.00 / $2,366.96
| Professional | | $1,591.00 | $1,853.00 | $2,366.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,277.09 / $3,305.00
| Professional | | $7.00 | $1,277.09 | $3,305.00 |