- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.89 / $3,807.79 / $14,309.50
| Professional | | $2,919.89 | $3,807.79 | $14,309.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,322.08 / $4,322.08 / $4,322.08
| Facility | | $4,322.08 | $4,322.08 | $4,322.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.34 / $4,322.08 / $4,644.35
| Professional | | $1,890.34 | $4,322.08 | $4,644.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,136.91 / $2,938.25 / $4,261.14
| Facility | | $2,136.91 | $2,938.25 | $4,261.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.94 / $4,322.08 / $5,675.60
| Professional | | $2,622.94 | $4,322.08 | $5,675.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,475.01 / $4,454.22 / $5,041.24
| Professional | | $3,475.01 | $4,454.22 | $5,041.24 |