- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.17 / $8,395.62 / $8,395.62
| Professional | | $1,763.17 | $8,395.62 | $8,395.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.67 / $2,540.67 / $2,540.67
| Facility | | $2,540.67 | $2,540.67 | $2,540.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.86 / $2,540.67 / $3,370.36
| Professional | | $1,966.86 | $2,540.67 | $3,370.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.42 / $3,186.30 / $3,313.04
| Facility | | $1,246.42 | $3,186.30 | $3,313.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.98 / $2,353.71 / $3,395.00
| Professional | | $1,568.98 | $2,353.71 | $3,395.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.78 / $2,000.78 / $2,000.78
| Facility | | $2,000.78 | $2,000.78 | $2,000.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.02 / $2,852.29 / $4,455.72
| Professional | | $2,500.02 | $2,852.29 | $4,455.72 |