- 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
- $4,067.94 / $4,067.94 / $4,067.94
| Facility | | $4,067.94 | $4,067.94 | $4,067.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.00 / $8,306.09 / $8,306.09
| Professional | | $2,083.00 | $8,306.09 | $8,306.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.13 / $1,534.63 / $2,263.31
| Facility | | $1,184.13 | $1,534.63 | $2,263.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.00 / $2,151.09 / $2,724.04
| Professional | | $1,517.00 | $2,151.09 | $2,724.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $1,360.20 / $2,548.50
| Professional | | $11.00 | $1,360.20 | $2,548.50 |