- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.76 / $2,453.81 / $9,158.96
| Professional | | $2,006.76 | $2,453.81 | $9,158.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,939.22 / $2,939.22 / $2,939.22
| Facility | | $2,939.22 | $2,939.22 | $2,939.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.26 / $2,939.22 / $3,150.37
| Professional | | $1,554.26 | $2,939.22 | $3,150.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,447.33 / $1,988.26 / $2,939.22
| Facility | | $1,447.33 | $1,988.26 | $2,939.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.46 / $2,935.94 / $3,811.50
| Professional | | $1,761.46 | $2,935.94 | $3,811.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,474.55 / $3,017.60 / $3,369.60
| Professional | | $2,474.55 | $3,017.60 | $3,369.60 |