- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.76 / $1,954.76 / $2,443.44
| Professional | | $1,954.76 | $1,954.76 | $2,443.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,422.85 / $1,919.77 / $5,448.50
| Facility | | $1,422.85 | $1,919.77 | $5,448.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.00 / $4,110.00 / $4,110.00
| Professional | | $1,564.00 | $4,110.00 | $4,110.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.85 / $1,058.85 / $1,564.00
| Facility | | $1,058.85 | $1,058.85 | $1,564.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.85 / $1,372.29 / $1,826.64
| Professional | | $1,058.85 | $1,372.29 | $1,826.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $1,146.70 / $1,875.90
| Professional | | $5.00 | $1,146.70 | $1,875.90 |