- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.40 / $1,986.71 / $2,483.38
| Professional | | $1,805.40 | $1,986.71 | $2,483.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,386.00 / $18,009.95 / $26,542.00
| Facility | | $1,386.00 | $18,009.95 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.00 / $6,677.33 / $6,677.33
| Professional | | $1,131.00 | $6,677.33 | $6,677.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.19 / $1,386.00 / $1,406.40
| Facility | | $1,085.19 | $1,386.00 | $1,406.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.19 / $1,386.00 / $1,876.63
| Professional | | $1,085.19 | $1,386.00 | $1,876.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $1,251.90 / $2,001.90
| Professional | | $5.00 | $1,251.90 | $2,001.90 |