- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.77 / $2,016.22 / $9,227.64
| Professional | | $1,634.77 | $2,016.22 | $9,227.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,803.04 / $2,803.04 / $2,803.04
| Facility | | $2,803.04 | $2,803.04 | $2,803.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,095.25 / $2,803.04 / $2,803.04
| Professional | | $2,095.25 | $2,803.04 | $2,803.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,803.04 / $3,364.40 / $3,488.24
| Facility | | $2,803.04 | $3,364.40 | $3,488.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.76 / $2,434.94 / $3,719.10
| Professional | | $1,718.76 | $2,434.94 | $3,719.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,639.76 / $3,170.91 / $7,300.92
| Professional | | $2,639.76 | $3,170.91 | $7,300.92 |