- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.58 / $2,371.58 / $2,964.48
| Professional | | $2,371.58 | $2,371.58 | $2,964.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,083.00 / $4,067.94
| Facility | | $55.00 | $2,083.00 | $4,067.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.00 / $2,300.41 / $8,306.09
| Professional | | $1,517.00 | $2,300.41 | $8,306.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.13 / $1,534.63 / $2,083.00
| Facility | | $1,184.13 | $1,534.63 | $2,083.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.96 / $1,907.00 / $2,300.41
| Professional | | $1,192.96 | $1,907.00 | $2,300.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $2,115.00 / $2,548.50
| Professional | | $11.00 | $2,115.00 | $2,548.50 |