- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,308.98 / $2,308.98 / $2,901.44
| Professional | | $2,308.98 | $2,308.98 | $2,901.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,096.94 / $2,569.13 / $2,569.13
| Facility | | $2,096.94 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.76 / $2,183.76 / $4,848.75
| Professional | | $2,183.76 | $2,183.76 | $4,848.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.25 / $2,308.98 / $2,901.44
| Facility | | $418.25 | $2,308.98 | $2,901.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.39 / $260.39 / $1,129.68
| Professional | | $260.39 | $260.39 | $1,129.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.11 / $198.36 / $1,687.74
| Professional | | $139.11 | $198.36 | $1,687.74 |