- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.14 / $2,383.14 / $9,100.45
| Professional | | $1,809.14 | $2,383.14 | $9,100.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,644.77 / $2,644.77 / $2,644.77
| Facility | | $2,644.77 | $2,644.77 | $2,644.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.13 / $2,352.32 / $2,644.77
| Professional | | $1,449.13 | $2,352.32 | $2,644.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.19 / $1,412.11 / $2,644.77
| Facility | | $1,300.19 | $1,412.11 | $2,644.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.44 / $2,429.41 / $3,550.40
| Professional | | $1,619.44 | $2,429.41 | $3,550.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.71 / $2,941.75 / $3,246.07
| Professional | | $2,586.71 | $2,941.75 | $3,246.07 |