- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,795.68 / $2,105.91 / $11,102.30
| Professional | | $1,795.68 | $2,105.91 | $11,102.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,381.95 / $3,381.95 / $3,381.95
| Facility | | $3,381.95 | $3,381.95 | $3,381.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.47 / $3,373.19 / $6,127.86
| Professional | | $1,991.47 | $3,373.19 | $6,127.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.00 / $2,772.43 / $3,889.24
| Facility | | $2,041.00 | $2,772.43 | $3,889.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.67 / $3,463.28 / $5,771.07
| Professional | | $2,128.67 | $3,463.28 | $5,771.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,956.76 / $3,617.92 / $4,717.21
| Professional | | $2,956.76 | $3,617.92 | $4,717.21 |