- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.65 / $2,480.65 / $3,100.82
| Professional | | $2,480.65 | $2,480.65 | $3,100.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,634.55 / $4,634.55 / $4,634.55
| Facility | | $4,634.55 | $4,634.55 | $4,634.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,711.23 / $8,711.23 / $8,711.23
| Professional | | $8,711.23 | $8,711.23 | $8,711.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,347.75 / $2,073.51 / $2,645.16
| Facility | | $1,347.75 | $2,073.51 | $2,645.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.68 / $2,220.17 / $2,971.64
| Professional | | $1,746.68 | $2,220.17 | $2,971.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,915.40 / $2,770.10
| Professional | | $7.00 | $1,915.40 | $2,770.10 |