- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.78 / $3,021.34 / $11,334.70
| Professional | | $2,276.78 | $3,021.34 | $11,334.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,401.93 / $3,401.93 / $3,401.93
| Facility | | $3,401.93 | $3,401.93 | $3,401.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.74 / $3,401.93 / $3,947.12
| Professional | | $1,799.74 | $3,401.93 | $3,947.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.87 / $2,298.82 / $3,420.49
| Facility | | $1,671.87 | $2,298.82 | $3,420.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.87 / $3,401.93 / $4,470.20
| Professional | | $2,065.87 | $3,401.93 | $4,470.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,962.08 / $3,607.59 / $4,128.29
| Professional | | $2,962.08 | $3,607.59 | $4,128.29 |