- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.19 / $2,537.65 / $9,501.09
| Professional | | $1,907.19 | $2,537.65 | $9,501.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,849.84 / $2,849.84 / $2,849.84
| Facility | | $2,849.84 | $2,849.84 | $2,849.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.09 / $2,849.84 / $3,450.68
| Professional | | $1,605.09 | $2,849.84 | $3,450.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,399.90 / $1,924.87 / $2,945.86
| Facility | | $1,399.90 | $1,924.87 | $2,945.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.37 / $2,849.84 / $3,902.77
| Professional | | $1,731.37 | $2,849.84 | $3,902.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.96 / $3,072.73 / $3,378.56
| Professional | | $2,481.96 | $3,072.73 | $3,378.56 |