- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.77 / $1,927.09 / $8,820.23
| Professional | | $1,426.77 | $1,927.09 | $8,820.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.58 / $2,681.58 / $2,681.58
| Facility | | $2,681.58 | $2,681.58 | $2,681.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.80 / $2,681.58 / $2,681.58
| Professional | | $1,810.80 | $2,681.58 | $2,681.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.58 / $2,928.90 / $3,039.80
| Facility | | $2,681.58 | $2,928.90 | $3,039.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.73 / $2,327.25 / $3,554.60
| Professional | | $1,642.73 | $2,327.25 | $3,554.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,356.10 / $2,957.67 / $4,698.99
| Professional | | $2,356.10 | $2,957.67 | $4,698.99 |