- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.82 / $2,464.75 / $9,238.40
| Professional | | $1,885.82 | $2,464.75 | $9,238.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,799.36 / $2,799.36 / $2,799.36
| Facility | | $2,799.36 | $2,799.36 | $2,799.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.97 / $2,799.36 / $3,010.10
| Professional | | $1,516.97 | $2,799.36 | $3,010.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.45 / $1,903.62 / $2,799.36
| Facility | | $1,384.45 | $1,903.62 | $2,799.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.11 / $2,799.36 / $3,670.10
| Professional | | $1,696.11 | $2,799.36 | $3,670.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.69 / $2,920.67 / $3,279.35
| Professional | | $2,534.69 | $2,920.67 | $3,279.35 |