- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.76 / $3,031.36 / $11,875.20
| Professional | | $1,807.76 | $3,031.36 | $11,875.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,725.75 / $2,725.75 / $2,725.75
| Facility | | $2,725.75 | $2,725.75 | $2,725.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.41 / $2,836.66 / $4,169.64
| Professional | | $1,728.41 | $2,836.66 | $4,169.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.30 / $2,093.44 / $3,430.69
| Facility | | $1,366.30 | $2,093.44 | $3,430.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.95 / $3,010.80 / $4,327.13
| Professional | | $1,965.95 | $3,010.80 | $4,327.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,120.18 / $3,777.77 / $4,560.87
| Professional | | $3,120.18 | $3,777.77 | $4,560.87 |