- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.00 / $2,181.14 / $11,505.70
| Professional | | $1,627.00 | $2,181.14 | $11,505.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,487.11 / $3,487.11 / $3,487.11
| Facility | | $3,487.11 | $3,487.11 | $3,487.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.93 / $3,365.12 / $5,969.53
| Professional | | $2,005.93 | $3,365.12 | $5,969.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.98 / $3,051.89 / $3,710.25
| Facility | | $2,147.98 | $3,051.89 | $3,710.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,173.06 / $3,577.59 / $5,961.55
| Professional | | $2,173.06 | $3,577.59 | $5,961.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.45 / $3,575.53 / $4,692.35
| Professional | | $2,925.45 | $3,575.53 | $4,692.35 |