- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.31 / $2,858.61 / $9,934.04
| Professional | | $1,887.31 | $2,858.61 | $9,934.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,018.09 / $3,018.09 / $3,018.09
| Facility | | $3,018.09 | $3,018.09 | $3,018.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.35 / $3,018.09 / $3,018.09
| Professional | | $2,245.35 | $3,018.09 | $3,018.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,018.09 / $3,650.40 / $3,772.23
| Facility | | $3,018.09 | $3,650.40 | $3,772.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.45 / $2,620.10 / $4,001.90
| Professional | | $1,849.45 | $2,620.10 | $4,001.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,864.16 / $3,425.71 / $5,289.14
| Professional | | $2,864.16 | $3,425.71 | $5,289.14 |