- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.64 / $2,837.55 / $9,884.79
| Professional | | $1,894.64 | $2,837.55 | $9,884.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,971.30 / $2,971.30 / $2,971.30
| Facility | | $2,971.30 | $2,971.30 | $2,971.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.01 / $2,971.30 / $2,971.30
| Professional | | $2,213.01 | $2,971.30 | $2,971.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,971.30 / $3,650.40 / $3,776.03
| Facility | | $2,971.30 | $3,650.40 | $3,776.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.01 / $2,593.98 / $3,962.00
| Professional | | $1,831.01 | $2,593.98 | $3,962.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,864.16 / $3,364.79 / $5,218.85
| Professional | | $2,864.16 | $3,364.79 | $5,218.85 |