- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.89 / $1,703.93 / $8,984.96
| Professional | | $1,438.89 | $1,703.93 | $8,984.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.67 / $2,754.67 / $2,754.67
| Facility | | $2,754.67 | $2,754.67 | $2,754.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.97 / $2,754.67 / $4,939.50
| Professional | | $1,620.97 | $2,754.67 | $4,939.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,696.81 / $2,361.23 / $3,125.82
| Facility | | $1,696.81 | $2,361.23 | $3,125.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.19 / $2,812.47 / $4,686.58
| Professional | | $1,717.19 | $2,812.47 | $4,686.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.42 / $2,902.40 / $3,813.66
| Professional | | $2,390.42 | $2,902.40 | $3,813.66 |