- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.09 / $1,860.63 / $9,858.31
| Professional | | $1,650.09 | $1,860.63 | $9,858.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,909.78 / $2,909.78 / $2,909.78
| Facility | | $2,909.78 | $2,909.78 | $2,909.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.60 / $2,909.78 / $5,290.32
| Professional | | $1,805.60 | $2,909.78 | $5,290.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,792.04 / $2,611.19 / $3,574.26
| Facility | | $1,792.04 | $2,611.19 | $3,574.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.63 / $2,955.36 / $4,924.68
| Professional | | $1,883.63 | $2,955.36 | $4,924.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,593.76 / $3,198.39 / $3,912.84
| Professional | | $2,593.76 | $3,198.39 | $3,912.84 |