- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.39 / $1,500.06 / $8,447.18
| Professional | | $1,401.39 | $1,500.06 | $8,447.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,709.97 / $2,709.97 / $2,709.97
| Facility | | $2,709.97 | $2,709.97 | $2,709.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.79 / $2,709.97 / $2,905.34
| Professional | | $1,757.79 | $2,709.97 | $2,905.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.73 / $2,858.70 / $3,067.63
| Facility | | $1,334.73 | $2,858.70 | $3,067.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.65 / $2,435.71 / $3,513.30
| Professional | | $1,623.65 | $2,435.71 | $3,513.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.84 / $2,858.70 / $4,722.10
| Professional | | $2,281.84 | $2,858.70 | $4,722.10 |