- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.10 / $1,865.16 / $9,686.54
| Professional | | $1,573.10 | $1,865.16 | $9,686.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,830.38 / $2,830.38 / $2,830.38
| Facility | | $2,830.38 | $2,830.38 | $2,830.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.76 / $2,830.38 / $5,312.12
| Professional | | $1,757.76 | $2,830.38 | $5,312.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,745.15 / $2,505.53 / $3,422.46
| Facility | | $1,745.15 | $2,505.53 | $3,422.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.72 / $2,939.72 / $4,898.62
| Professional | | $1,865.72 | $2,939.72 | $4,898.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,535.64 / $3,129.09 / $3,894.06
| Professional | | $2,535.64 | $3,129.09 | $3,894.06 |