- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.37 / $9,465.83 / $9,465.83
| Professional | | $2,264.37 | $9,465.83 | $9,465.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,807.77 / $2,807.77 / $2,807.77
| Facility | | $2,807.77 | $2,807.77 | $2,807.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.54 / $2,807.77 / $3,011.85
| Professional | | $2,075.54 | $2,807.77 | $3,011.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.06 / $3,341.00 / $3,422.46
| Facility | | $1,388.06 | $3,341.00 | $3,422.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.38 / $2,547.83 / $3,675.00
| Professional | | $1,698.38 | $2,547.83 | $3,675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.40 / $3,123.00 / $4,889.55
| Professional | | $2,621.40 | $3,123.00 | $4,889.55 |