- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,292.79 / $9,570.81 / $9,570.81
| Professional | | $2,292.79 | $9,570.81 | $9,570.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,829.86 / $2,829.86 / $2,829.86
| Facility | | $2,829.86 | $2,829.86 | $2,829.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.98 / $2,829.86 / $3,044.44
| Professional | | $2,092.98 | $2,829.86 | $3,044.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,398.38 / $3,410.55 / $3,484.44
| Facility | | $1,398.38 | $3,410.55 | $3,484.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.11 / $2,577.42 / $3,717.70
| Professional | | $1,718.11 | $2,577.42 | $3,717.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.97 / $3,159.61 / $4,940.43
| Professional | | $2,675.97 | $3,159.61 | $4,940.43 |