- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.29 / $1,935.89 / $10,202.20
| Professional | | $1,657.29 | $1,935.89 | $10,202.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,119.57 / $3,119.57 / $3,119.57
| Facility | | $3,119.57 | $3,119.57 | $3,119.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.13 / $3,109.95 / $5,592.70
| Professional | | $1,854.13 | $3,109.95 | $5,592.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,922.33 / $2,590.50 / $3,569.83
| Facility | | $1,922.33 | $2,590.50 | $3,569.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.81 / $3,189.37 / $5,314.63
| Professional | | $1,946.81 | $3,189.37 | $5,314.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,720.83 / $3,335.04 / $4,178.46
| Professional | | $2,720.83 | $3,335.04 | $4,178.46 |