- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.61 / $2,394.33 / $9,256.67
| Professional | | $1,888.61 | $2,394.33 | $9,256.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,975.50 / $2,975.50 / $2,975.50
| Facility | | $2,975.50 | $2,975.50 | $2,975.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.07 / $2,847.14 / $2,975.50
| Professional | | $1,564.07 | $2,847.14 | $2,975.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,465.18 / $1,957.73 / $2,975.50
| Facility | | $1,465.18 | $1,957.73 | $2,975.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.78 / $2,847.14 / $3,859.80
| Professional | | $1,783.78 | $2,847.14 | $3,859.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,498.51 / $3,030.11 / $3,508.55
| Professional | | $2,498.51 | $3,030.11 | $3,508.55 |