- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.79 / $13,903.50 / $13,903.50
| Professional | | $1,898.79 | $13,903.50 | $13,903.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $5,251.41 / $5,251.41
| Facility | | $2,756.64 | $5,251.41 | $5,251.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,756.64 / $5,251.41 / $5,251.41
| Professional | | $2,756.64 | $5,251.41 | $5,251.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,459.58 / $5,001.34 / $5,251.41
| Facility | | $2,459.58 | $5,001.34 | $5,251.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,881.76 / $4,028.77 / $5,255.22
| Professional | | $3,881.76 | $4,028.77 | $5,255.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.22 / $2,200.91 / $2,519.42
| Professional | | $1,989.22 | $2,200.91 | $2,519.42 |