- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,684.23 / $9,310.11 / $9,310.11
| Professional | | $2,684.23 | $9,310.11 | $9,310.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $2,929.03 / $2,929.03
| Facility | | $1,743.07 | $2,929.03 | $2,929.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.07 / $2,929.03 / $2,929.03
| Professional | | $1,743.07 | $2,929.03 | $2,929.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,555.24 / $2,789.55 / $2,929.03
| Facility | | $1,555.24 | $2,789.55 | $2,929.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.36 / $2,247.09 / $3,191.91
| Professional | | $2,198.36 | $2,247.09 | $3,191.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.82 / $1,391.68 / $2,144.53
| Professional | | $1,257.82 | $1,391.68 | $2,144.53 |