- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.15 / $2,100.98 / $9,617.28
| Professional | | $1,808.15 | $2,100.98 | $9,617.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,921.87 / $2,921.87 / $2,921.87
| Facility | | $2,921.87 | $2,921.87 | $2,921.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.94 / $2,921.87 / $2,921.87
| Professional | | $2,222.94 | $2,921.87 | $2,921.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,921.87 / $3,641.30 / $3,675.10
| Facility | | $2,921.87 | $3,641.30 | $3,675.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.25 / $2,536.23 / $3,873.80
| Professional | | $1,790.25 | $2,536.23 | $3,873.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,844.40 / $3,282.00 / $5,121.71
| Professional | | $2,844.40 | $3,282.00 | $5,121.71 |