- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.90 / $2,457.34 / $9,234.66
| Professional | | $1,880.90 | $2,457.34 | $9,234.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,788.32 / $2,788.32 / $2,788.32
| Facility | | $2,788.32 | $2,788.32 | $2,788.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.26 / $2,788.32 / $3,001.37
| Professional | | $1,006.26 | $2,788.32 | $3,001.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,041.33 / $1,380.22 / $2,788.32
| Facility | | $1,041.33 | $1,380.22 | $2,788.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.11 / $2,788.32 / $3,657.50
| Professional | | $1,609.11 | $2,788.32 | $3,657.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.85 / $2,872.24 / $4,410.95
| Professional | | $2,241.85 | $2,872.24 | $4,410.95 |