- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.88 / $1,955.88 / $2,475.67
| Professional | | $1,955.88 | $1,955.88 | $2,475.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,032.02 / $2,387.48 / $2,387.48
| Facility | | $2,032.02 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.33 / $2,387.48 / $2,387.48
| Professional | | $284.33 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,752.08 / $1,955.88 / $2,475.67
| Facility | | $1,752.08 | $1,955.88 | $2,475.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,705.40 / $2,705.40 / $2,705.40
| Professional | | $2,705.40 | $2,705.40 | $2,705.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.66 / $811.24 / $1,502.30
| Professional | | $112.66 | $811.24 | $1,502.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.36 / $1,237.94 / $2,258.64
| Professional | | $829.36 | $1,237.94 | $2,258.64 |