- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.75 / $2,320.30 / $10,514.40
| Professional | | $1,652.75 | $2,320.30 | $10,514.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,383.52 / $3,383.52 / $3,383.52
| Facility | | $3,383.52 | $3,383.52 | $3,383.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.05 / $2,962.38 / $3,383.52
| Professional | | $1,513.05 | $2,962.38 | $3,383.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,658.59 / $2,073.23 / $3,299.12
| Facility | | $1,658.59 | $2,073.23 | $3,299.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.30 / $3,129.79 / $4,417.70
| Professional | | $1,904.30 | $3,129.79 | $4,417.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,612.13 / $2,612.13 / $11,831.32
| Facility | | $2,612.13 | $2,612.13 | $11,831.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.40 / $3,314.29 / $3,819.27
| Professional | | $2,175.40 | $3,314.29 | $3,819.27 |