- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.18 / $2,081.19 / $9,531.27
| Professional | | $1,812.18 | $2,081.19 | $9,531.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,879.81 / $2,879.81 / $2,879.81
| Facility | | $2,879.81 | $2,879.81 | $2,879.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.65 / $2,879.81 / $2,879.81
| Professional | | $2,145.65 | $2,879.81 | $2,879.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,879.81 / $3,488.55 / $3,613.47
| Facility | | $2,879.81 | $3,488.55 | $3,613.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.04 / $2,514.69 / $3,840.90
| Professional | | $1,775.04 | $2,514.69 | $3,840.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,737.17 / $3,248.40 / $5,059.74
| Professional | | $2,737.17 | $3,248.40 | $5,059.74 |