- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.08 / $1,869.30 / $9,441.53
| Professional | | $1,476.08 | $1,869.30 | $9,441.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,787.79 / $2,787.79 / $2,787.79
| Facility | | $2,787.79 | $2,787.79 | $2,787.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.55 / $2,787.79 / $5,034.59
| Professional | | $1,729.55 | $2,787.79 | $5,034.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.10 / $2,370.17 / $3,278.25
| Facility | | $1,637.10 | $2,370.17 | $3,278.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.39 / $2,828.64 / $4,713.53
| Professional | | $1,802.39 | $2,828.64 | $4,713.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.53 / $3,005.55 / $3,740.32
| Professional | | $2,435.53 | $3,005.55 | $3,740.32 |